Development and evaluation of an

augmentative and alternative communication

training for caregivers of young children in a
low-income rural context of South Africa

by

Vuledzani P. Ndanganeni
Student no: 11374633

A thesis submitted in partial fulfilment of the requirements for the degree

Philosophiae Doctor in
Augmentative and Alternative Communication

in the Centre for Augmentative and Alternative Communication

Faculty of Humanities

UNIVERSITY OF PRETORIA

SUPERVISOR: Professor KM Tönsing

CO-SUPERVISOR: Professor J Bornman

30 November 2022
 DECLARATION OF ORIGINALITY
.

Full names of student: Vuledzani P. Ndanganeni

Student number: u11374633

Declaration

1. I understand what plagiarism is and am aware of the University’s policy in this regard.

2. I declare that this dissertation is my own original work. Where other people’s work has
been used (either from a printed source, Internet or any other source), this has been properly
acknowledged and referenced in accordance with departmental requirements.

3. I have not used work previously produced by another student or any other person to hand
in as my own.

4. I have not allowed, and will not allow, anyone to copy my work with the intention of
passing it off as his or her own work.

SIGNATURE OF STUDENT:

SIGNATURE OF SUPERVISOR:
 ETHICS STATEMENT

The author, whose name appears on the title page of this dissertation, has obtained, for
the research described in this work, the applicable research ethics approval.

The author declares that she has observed the ethical standards required in terms of the
University of Pretoria’s Code of ethics for researchers and the Policy guidelines for responsible
research.

ii
 Acknowledgements
Glory to God Almighty!
Yehova muthu u tou vha mini Vhone vha tshi muelwa, Vha mu ambadza Vhugala havho na
Lunako. {Lord who am I that you are mindful of, You have crowned me with Your glory and
honour}. Excerpts from Psalm 8:4
I am grateful to the Lord God Almighty for giving me peace that surpasses all human
understanding through this journey. There were times I did not know if I was coming or going,
but, through His Grace I have learned to feed my heart kindness, peace and above all love. I have
learned lessons (academically and personally) that I never thought I would have learned had it
not been for His mindfulness of me.
There is a saying in Tshivenda that “a man is not an island”. I have experienced it first hand
during this PhD journey. I am blessed and grateful for the supports received, encouragements,
blessings and kind gestures in all forms. I would like to appreciate and thank the following
people and institutions:
• My supervisor Professor Kerstin Tönsing for having faith in my project and her
dedication towards my supervision in all seasons. Thank you Prof for the constructive
criticism, advice and being meticulous in all you did. Your hard work, blood, sweat and
tears have surely paid off. You have taught me a lot of lessons directly and indirectly
which I will take forward in life and academia.
• My co-supervisor Professor Juan Bornman. Thank you for shaping my life in academia in
all the ways you have done, including pushing me to enrol for a PhD. I have learned a lot
from you and I still ask myself how you get through all that you get through in academia.
You are surely a well of wisdom to some of us. Methodology has never looked good and
that is what I have taken from you throughout the years. I also just want a glass as
opposed to seeing it half full or half empty (inside joke but true).
• The director at the Centre for AAC and PhD programme director, Professor Shakila
Dada. Thank you for managing the programme the way you managed it and being
flexible enough to change course during Covid-19. Your support and encouragement is
appreciated.
• The National Institute for Humanities and Social Sciences whom I refer to as “my
blessers”. Undertaking PhD is not easy without funding. They have been my providers

iii
 to see to me through this multi phased study that needed finances. I do not know what I
would have done without the financial aid. Additionally, I am grateful for the mentorship
programme that exposed me to various mentors from different fields. The expertise was
out of this world. Thank you for making sure we could take time to write and progress
with our studies in every way possible. To all my mentors, you are simply the best. I am
grateful for the experiences NIHSS afforded me with throughout my journey.
• Thank you Thabelo and Johanna for accommodating me at your farm and allowing me to
camp for the first 90 days of me getting started with data collection. Thank you for all the
meals and basic needs you provided. To my family, those I have lost along the way and
the ones who are alive to see this come to pass, I am grateful for the encouragement,
support, critique and all the spoils I have received from you. Special mentions to Thabelo,
Johanna, Oluga, Arehone, my Mom, niece and nephew. Thank you for everything you do
for me and all the well wishes as well as prayers. At times you did not understand but you
listened. To the village I belong to, thank you to all my brothers, sisters, uncles, aunts and
grandparents for the conversations and understanding why I could not attend family
functions. I am grateful.
• To the Queens – thank you for sharing this PhD journey with me, without you I don’t
know how it would feel to have PhD conversations, methodology conversations and
debriefing sessions when the going gets tough. Thank you for being my sounding boards,
my proof readers and brainstorming team. We have spent sleepless nights together doing
what needs to be done. Thank you for all the pushes and encouragement and not
forgetting the blessings. I am because you are!
• To the family of friends I keep; most of you did not understand my decisions for
abandoning our meetings and coffee dates, for others it was “don’t bring your laptop to
coffee”. However, through it all you kept pushing and checking up on me. You listened to
my rants and offered prayers, hugs and words of courage. I am eternally grateful to all of
you. To the the Siyathwalisana gang, I am grateful for the sessions we had to push each
other and disseminate knowledge amongst one another. Thank you ever so much.
• My study would not be what it has been had it not been for the participants and their
families. To the participants in all the phases of my study starting with the Vhavenda
cultural stakeholders: Thank you for taking time out of your busy schedules to participate

iv
 and share the knowledge you shared. I learned a lot about my culture through our
conversations. I am eternally grateful {ndo livhuwa nga maanda}. To my expert panel of
SLPs and the SLPs in Vhembe who assisted and accommodated my study, I am grateful
for all your efforts. To all the gatekeepers for seeing value and significance in my and
granting me permission to conduct the study, I appreciate. How do I forget the caregivers
who opened their hearts and consented to participating in this study? Thank you so much
for affording me the opportunity to come into your homes and conduct the study. I have
learned many life lessons in our encounters outside of the research. Murena a vha ite nga
vhuthu and dzulele u livhanya tshifhatuwo Tshawe navho misi yothe. Mudau wa
Thenzheni uri Aa!!!
• The Nephawe’s (mom, Tshilidzi and Candi) for encouraging, supporting and being kind
enough to adopt me through the data collection process. Thank you for feeding me and
accommodating me in your home. I am grateful and blessed. Sesi Thifheli Netshisaulu-
Kutama for opening up your home and feeding me, I do not take it for granted. Thank
you for the support and chats. My friend Faith for allowing me to run her household in
her absence during this time, mungana, I am eternally grateful for everything. To Mulalo
and Masala, thank you for being selfless in allowing me to rent your car throughout at
Vule rates. Thank you for entrusting me with your cars at different phases of data
collection. May God continue to replenish your barns and storehouses for the generosity
and kindness.
• My research assistants- thank you for taking time out of your busy schedules to meet
deadlines and being meticulous in all the work done. You were also my greatest critics.
You made data analysis fun and easy. I am grateful for your efforts and hard work. A
special appreciation goes out to the team that assisted with translations. I appreciate your
hard work and dedication. Thank you for Tshivenda 301 lessons on a daily basis.
• To conclude, my heartfelt thank you to my precious offspring and girl after mommy’s
heart. Thank you for allowing me to partially parent you. You have taught me and
allowed me to experience the true meaning of the African proverb: “it takes a village to
raise a child”. Had it not been for your openness, I would have quit a long time ago.
Thank you Azwinndini Mufunwa Madima for who you are. You are special. I hope you
are encouraged to go out there and do what your heart desires.

v
 To everyone I couldn’t mention herein, thank you for all your contributions in my life
throughout this journey. Your encouragement, words of wisdom, lessons taught and the love
shown, I appreciate it.
Izandla zedlula ikhanda
Mudau wa Thenzheni uri Aa!! Ndo livhuwa nga maandesa!!!

vi
TABLE OF CONTENTS DECLARATION OF ORIGINALITY ............................................. i
List of Tables............................................................................................................................... xiii
List of Figures.............................................................................................................................. xv
List of Appendices ...................................................................................................................... xvi
Abstract....................................................................................................................................... xix
CHAPTER 1 .................................................................................................................................. 1
PROBLEM STATEMENT AND RATIONALE ........................................................................ 1
1.1 Introduction ......................................................................................................................... 1
1.2 Problem statement and rationale ......................................................................................... 1
1.3 Terminology ........................................................................................................................ 3
1.3.1 Augmentative and alternative communication (AAC) ............................................................ 4
1.3.2 Caregiver ................................................................................................................................. 4
1.3.3 Caregiver-mediated communication interventions ................................................................. 4
1.3.4 Caregiver training.................................................................................................................... 4
1.3.5 Communicative turn ................................................................................................................ 4
1.3.6 Child using augmented output................................................................................................. 5
1.3.7 Contingent responding ............................................................................................................ 5
1.3.8. Cultural stakeholder ................................................................................................................ 5
1.3.9. Modelling aided language input .............................................................................................. 5
1.3.10. Offering communication opportunities ................................................................................... 5
1.3.11. Social validity.......................................................................................................................... 6
1.3.12. Training program .................................................................................................................... 6
1.3.13. Vhavenda................................................................................................................................. 6
1.4. Abbreviations ...................................................................................................................... 6
1.5. Models for developing interventions .................................................................................. 7
1.6. Outline of chapters .............................................................................................................. 8
1.7. Summary ........................................................................................................................... 10
CHAPTER 2 ................................................................................................................................. 11
LITERATURE REVIEW............................................................................................................ 11
2.1 Introduction ........................................................................................................................11
2.2 Language and communication development ......................................................................11
2.3 Children with complex communication needs .................................................................. 15
2.4 AAC for children with CCN ............................................................................................. 17
2.5 Caregiver training to improve communication of children using or in need of AAC ...... 19
2.6 Culturally and linguistically responsive AAC service provision ...................................... 23

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2.7 Provision of AAC services in the South African context .................................................. 25
2.8 Conceptual framework ...................................................................................................... 28
2.9 Summary ........................................................................................................................... 30
CHAPTER 3 ................................................................................................................................ 32
METHODOLOGY ..................................................................................................................... 32
3.1 Introduction ....................................................................................................................... 32
3.2 Aims of the study .............................................................................................................. 32
3.2.1 Main aim of the study ........................................................................................................... 32
3.2.2 Sub-aims................................................................................................................................ 32
3.3 Research paradigm ............................................................................................................ 33
3.4 Research design................................................................................................................. 34
3.5 Phases of the study ............................................................................................................ 35
3.1 Summary ........................................................................................................................... 36
CHAPTER 4 ................................................................................................................................ 36
PHASE 1.1: SCOPING REVIEW OF CAREGIVER TRAINING PROGRAMMES ......... 36
4.1. Introduction ....................................................................................................................... 37
4.2. Rationale ........................................................................................................................... 37
4.3 Aims .................................................................................................................................. 38
4.3.1 Main aim ............................................................................................................................... 38
4.3.2 Sub-aims................................................................................................................................ 38
4.4 Methods ............................................................................................................................. 38
4.4.1 Protocol ............................................................................................................................. 38
4.5 Results ............................................................................................................................... 41
4.5.1 Descriptive information .......................................................................................................... 43
4.5.2 Participants .............................................................................................................................. 44
4.5.3 Training .............................................................................................................................. 45
4.5.3.1 Delivery ................................................................................................................................. 45
4.5.3.2 Content .................................................................................................................................. 45
4.5.4 Outcomes............................................................................................................................... 48
4.5.5 Social validity: Caregiver input into programme and evaluation of social validity post-
training 50
4.7 Summary ........................................................................................................................... 52
CHAPTER 5 ................................................................................................................................ 53
PHASE 1.2: CULTURAL STAKEHOLDERS INTERVIEWS .............................................. 53
5.1. Introduction ....................................................................................................................... 53

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5.2. Aim of Phase 1.2 ............................................................................................................... 53
5.2.1 Main aim of Phase 1.2............................................................................................................. 53
5.2.2 Sub-aims of Phase 1.2 ............................................................................................................. 53
5.3. Design ............................................................................................................................... 53
5.4. Participants ........................................................................................................................ 54
5.4.1 Sampling .................................................................................................................................. 54
5.4.2 Recruitment ............................................................................................................................. 54
5.4.3 Selection criteria ...................................................................................................................... 54
5.4.4 Descriptive criteria .................................................................................................................... 55
5.5 Pilot investigations ............................................................................................................ 58
5.5.1 Pilot Investigation I ............................................................................................................... 58
5.5.2 Pilot Investigation II .............................................................................................................. 62
5.6 Materials and instruments ................................................................................................. 64
5.6.1 Information letter and consent form ...................................................................................... 64
5.6.2 Other equipment and materials ............................................................................................. 64
5.6.3. Development of the interview schedule ................................................................................ 66
5.7 Data collection procedures ................................................................................................ 76
5.8 Data analysis ..................................................................................................................... 77
5.8.1 Transcription ......................................................................................................................... 77
5.8.2 Translation of the transcripts ................................................................................................. 78
5.8.3 Coding ................................................................................................................................... 78
5.9 Trustworthiness of data ..................................................................................................... 80
5.10 Ethical considerations ....................................................................................................... 81
5.11 Findings ............................................................................................................................. 82
5.11.1 Theme 1: Typical interactions of young children ................................................................. 83
5.11.2 Theme 2: Communication disabilities................................................................................... 90
5.11.3 Theme 3: Acceptability, appropriateness and suggestions for the proposed training ........... 96
5.11.4 Theme 4: Changes over time ............................................................................................... 101
5.12 Implications for the development phase ..................................................................... 103
5.13 Summary ........................................................................................................................ 104
CHAPTER 6 .............................................................................................................................. 106
PHASE 2: DEVELOPMENT OF THE CAREGIVER TRAINING PROGRAMME ....... 106
6.1. Introduction ..................................................................................................................... 106
6.2. Aims of Phase 2 .............................................................................................................. 107
6.2.1 Main aim of Phase 2 ............................................................................................................ 107

ix
 6.2.2 Sub-aims of Phase 2 .............................................................................................................. 107
6.3. Overview of the development of the caregiver training programme .............................. 108
6.3.1 Design and Development paradigm (Thomas and Rothman, 1994) ................................... 108
6.3.2 Input that informed the CgTP.............................................................................................. 109
6.4 Overview of the CgTP: Materials and content ................................................................ 120
6.4.1 Overview of the programme ............................................................................................... 120
6.4.2 Development of materials ................................................................................................... 128
6.5 Expert review .................................................................................................................. 139
6.5.1 Results of the expert review process ................................................................................... 139
6.6 Pilot investigation ........................................................................................................... 144
6.6.1 Participants .......................................................................................................................... 144
6.6.2 Aims, materials, procedures, results and recommendations................................................ 145
6.7. Implications for the evaluation phase ............................................................................. 153
6.8. Summary ......................................................................................................................... 153
CHAPTER 7 .............................................................................................................................. 154
PHASE 3: EVALUATION OF THE CAREGIVER TRAINING PROGRAMME -
METHODOLOGY ................................................................................................................... 154
7.1 Introduction ..................................................................................................................... 154
7.2 Aims of Phase 3 .............................................................................................................. 155
7.2.1 Main aim of Phase 3 ............................................................................................................ 155
7.2.2 Sub-aims of Phase 3 ............................................................................................................ 155
7.3 Stages of Phase 3............................................................................................................. 156
7.4 Design ............................................................................................................................. 156
7.5 Participants ...................................................................................................................... 159
7.5.1 Sampling ............................................................................................................................. 159
7.5.2 Recruitment ......................................................................................................................... 159
7.5.3 Selection criteria.................................................................................................................. 160
7.5.4 Screening procedures .......................................................................................................... 162
7.5.5 Screening and selection of participants ............................................................................... 162
7.5.6 Descriptive criteria .............................................................................................................. 164
7.6 Materials, instruments, and equipment ........................................................................... 165
7.6.1 Material for Recruitment ..................................................................................................... 165
7.6.2 Instruments, Materials and Equipment for Screening ......................................................... 166
7.6.3 Materials and Equipment for the Experimental Stage: Training and Measurement ........... 170
7.6.3.2 Equipment ........................................................................................................................... 170

x
7.7 Procedures ....................................................................................................................... 171
7.7.1 Pre-experimental procedures ............................................................................................... 172
7.7.2 Experimental procedures ..................................................................................................... 173
7.8 Data Analysis .................................................................................................................. 178
7.8.1 Recording of DVs ............................................................................................................... 178
7.8.2 Data Analysis ...................................................................................................................... 179
7.9 Procedural fidelity and reliability of recording dependent variables ............................ 181
7.9.2 Reliability of Recording the Dependent Variables.............................................................. 182
7.9.3 Validity................................................................................................................................ 185
7.10 Ethical considerations ..................................................................................................... 186
7.11 Summary ......................................................................................................................... 187
CHAPTER 8 .............................................................................................................................. 189
PHASE 3: EVALUATION OF THE CAREGIVER TRAINING PROGRAMME –
RESULTS................................................................................................................................... 189
8.1 Introduction ..................................................................................................................... 189
8.2 Overview of results ......................................................................................................... 189
8.3 Caregiver contingent responding .................................................................................... 191
8.4 Caregiver offering communication opportunities ........................................................... 194
8.4.1 Caregiver modelling aided language input ..................................................................... 195
8.5 Child communicative turns ............................................................................................. 197
8.6 Child using augmented output ........................................................................................ 199
8.7 Social validity ................................................................................................................. 200
8.8 Summary ......................................................................................................................... 203
CHAPTER 9 .............................................................................................................................. 204
PHASE 3: EVALUATION OF THE CAREGIVER TRAINING PROGRAME -
DISCUSSION ............................................................................................................................ 204
9.1. Introduction ..................................................................................................................... 204
9.2. The effects of CgTP on the caregiver variables .............................................................. 204
9.3. The effects of caregiver training on the child variables .................................................. 209
9.4. Reasons for the results obtained.......................................................................................211
9.4.1. Characteristics of the CgTP................................................................................................. 212
9.4.2. Theoretical underpinnings: Transactional Model of Development ..................................... 213
9.4.3. Social and cultural validity of the intervention ................................................................... 215
CHAPTER 10 ............................................................................................................................ 219
10.1 Introduction ..................................................................................................................... 219

xi
10.2 Summary of the results and conclusions ......................................................................... 219
10.2.1. The summary of this thesis is organised according to the three phases of the study.1 Phase 1:
Exploratory phase ............................................................................................................................. 219
10.2.2 Phase 2: Development phase ............................................................................................... 220
10.2.3 Phase 3: Evaluation phase ................................................................................................... 220
10.3 Implications for practice ................................................................................................. 222
10.4 Evaluation of the study.................................................................................................... 225
10.4.1 Strengths of the study .......................................................................................................... 225
10.4.2 Limitations of the study....................................................................................................... 228
10.5 Recommendations for future research ............................................................................ 229
10.6 Summary ......................................................................................................................... 231
References ................................................................................................................................... 232

xii
 List of Tables

Table 4.1 Inclusion and Exclusion Criteria for Studies 39

Table 4.2 AAC Systems and Symbols Used Across the Studies 45
Table 4.3 Frequency of Instructional Strategies (in Descending Order) 48
Table 5.1 Selection Criteria 55
Table 5.2 Description of Participants 56
Table 5.3 Pilot I: Aims, Materials, Procedures/Methods, Outcomes and 59
Recommendations
Table 5.4 Pilot II Aims, Materials, Methods/Procedures, Outcomes and 63
Recommendations
Table 5.5 Materials Description and Rationale 64
Table 5.6 Interview Schedule Development 67
Table 5.7 Thematic Analysis Process (Braun & Clarke, 2013) 78
Table 5.8 Theme 1: Typical Interactions of Young Children 83
Table 5.9 Theme 2: Communication Disabilities 90
Table 5.10 Theme 3: Acceptability, Appropriateness and Suggestions for the 92
Proposed Training
Table 5.11 Theme 4: Changes Over Time 101
Table 6.1 Steps Used to Develop the CgTP (Adapted from Thomas And Rothman, 108
1994)
Table 6.2 Application of Adult Learning Principles to the Proposed CgTP 113
Table 6.3 Input from Exploratory Phase to Programme Development 115
Table 6.4 Overview of the Programme: Activities, Aims, Description of Activities, 121
Materials and Equipment
Table 6.5 Tablet Training Leaflet Content 129
Table 6.6 Biographical Questionnaire Description 129
Table 6.7 Recognition and Representational Level Of PCS 131
Table 6.8 Activities and Materials Developed For The Experimental Stage 132
Table 6.9 Activity Boards Vocabulary 134
Table 6.10 Post-Intervention Survey Description 137

xiii
Table 6.11 Expert Review Results 139
Table 6.12 Pilot Aims, Materials/Equipment, Procedures, Results and 146
Recommendations
Table 7.1 Caregiver and Child-Related Dependant Variables: Operational 157
Definitions
Table 7.2 Selection Criteria for Caregivers 160
Table 7.3 Selection Criteria for Children 161
Table 7.4 Reasons for Excluding Participants 163
Table 7.5 Toys Used for Screening 169
Table 7.6 Screening Equipment Description 170
Table 7.7 Training and Measurement Equipment Description 171
Table 7.8 Screening Tool Administration and Order 172
Table 7.9 Within Condition Visual Analysis Steps (Lane & Gast, 2013;2014) 179
Table 7.10 Between Condition Visual Analysis Steps (Lane & Gast, 2013;2014) 179
Table 7.11 Procedural fidelity of The probes for All Participants and for All 181
Conditions
Table 7.12 Percentage of Agreement for Training and Guided Practice and 182
Feedback Sessions
Table 7.13 IOA for CCD1 184
Table 7.14 IOA for CCD2 184
Table 7.15 IOA for CCD3 184
Table 8.1 Contingent Responding Nap Values 192
Table 8.2 Offering Communication Opportunities NAP Values With Their 195
Interpretation
Table 8.3 Modelling aided language input NAP Values With Their Interpretation 196
Table 8.4 Child communicative turns NAP Values With Their Interpretation 198
Table 8.5 Child Using Augmented Output NAP Values and Their Interpretation 199
Table 8.6 Averages Caregiver ratings for constructs 200
Table 8.7 Parent-Report of Words and Word-Approximations Spoken by Children 202
Post Intervention

xiv
 List of Figures

Figure 2.1 Conceptual Framework 29

Figure 3.1 Overview of the Phases 35
Figure 4.1 Study Selection PRISMA (2009) Flowchart 42
Figure 6.1 Overview of Methodology 105
Figure 6.2 Input That Informed the Development Phase 109
Figure 7.1 Overview of Methodology 153
Figure 7.2 Stages of Phase 3 156
Figure 8.1 Visual Representation of the Results 190

xv
 List of Appendices

Appendix A Ethical Clearance from the Faculty of Humanities Research Ethics 258
Committee
Appendix B B1 Department of Health Limpopo Ethical Clearance 259
B2 Vhembe District Health Ethical Clearance 260
B3 Hospitals Ethical Clearance 261
Appendix C C1 Search Strategy per Database 268
C2 Scoping Review Summary of Studies 271
Appendix D D1 Cultural Stakeholder Interviews Participant Information Letter 284
(English)
D2 Cultural Stakeholder Interviews Participant Consent form (online
287
English )
D3 Cultural Stakeholder Interviews Participant Information Letter
(Tshivenda) 288
D4 Cultural Stakeholder Interviews Participant Consent form (online 290
Tshivenda)
D5 Cultural Stakeholder Interviews -Interview Schedule (English) 292
D6 Cultural Stakeholder Interviews -Interview Schedule (Tshivenda) 296
D7 Interview Material- Videos 300
D8 Interview Material-Communication Board 303
D9 Synthesized Member Checking (email) 304
D10 Synthesized Member Checking Summary 305
Appendix E E1 Biographical Questionnaire 309
E2 Biographical Questionnaire Flash Cards 317
Appendix F Communication Matrix 318
Appendix G G1 Picture Recognition and Representational Task Procedural Script 319
G2 Picture Recognition and Representational Task 321
G3 Picture Recognition and Representational Task Scoring Form 322
Appendix H Visual Function Classification System 323

xvi
Appendix I I1 Mini- Manual Abilities Classification System 324
I2 Manual Abilities Classification System 325
Appendix J Materials for eliciting fine motor skills 326
Appendix K Pre- Intervention Commitment Form 327
Appendix L L1 Tablet Training Leaflet with a Script (English) 329
L2 Tablet Leaflet with a Script (Tshivenda) 329
Appendix M Communication Boards (Activity Boards) 330
Appendix N Procedural Fidelity Script – Baseline, Intervention and Maintenance 336
Condition
Appendix O O1 Day 1 training presentation (English) 337
O2 Day 1 training presentation (Tshivenda) 338
O3 Training materials - Communication Board example 339
O4 Day 1 Training procedural script 340
Appendix P P1 Training Booklet (English) 345
P2 Training Booklet (Tshivenda) 346
Appendix Q Q1 Day 2 Training Presentation (English) 347
Q2 Day 2 Training Presentation (Tshivenda) 348
Q3 Day 2 Training Procedural Script 349
Appendix R Verbal Rehearsal of Strategy Recording Form 352
Appendix S Guided Practice with Feedback Session Procedural Script 353
Appendix T T1 Post Intervention Survey 354
T2 Post Intervention Survey Likert Scale Flashcards 358
Appendix U Post intervention Commitment Statement Template 359
Appendix V Timed Event Recording Form 360
Appendix W W1 Expert Panel Information Letter and Consent Form 361
W2 Expert panel question template 364
Appendix X Pilot Study – Graph of Results 369
Appendix Y Y1 SLP Recruitment Email 370

xvii
Y2 Caregiver Information Letter With Consent Form (English) 372
Y3 Consent Form 376

xviii
 Abstract

Background: Training caregivers of young children with complex communication needs to

implement augmentative and alternative communication methods has resulted in various
communication gains for children. Such training may be a feasible, effective and socially valid
way of improving children’s communication outcomes in contexts where access to rehabilitation
professionals and resources is limited.
Method: This study employed an exploratory sequential mixed method design to develop and
evaluate a programme aimed at training Vhavenda caregivers of children living in low-income
contexts to implement augmentative and alternative communication strategies with their children
aged 2-6 years living with complex communication needs. In the exploratory phase, a scoping
review of the literature as well as interviews with cultural stakeholders generated data that
informed program design undertaken during the development phase. The development phase also
comprised an expert review and pilot study to further refine the programme. The evaluation
phase entailed testing the effects of the programme on three caregiver and two child variables by
means of a single case multiple probe design across three caregiver-child dyads. The social
validity of the programme was also evaluated.
Results: Medium to strong effects of the intervention on the five variables were established but
were not maintained three weeks post intervention. Social validity of the programme was found
to be high.
Conclusion: The caregivers were able to implement the strategies taught during the guided
practice phase, attesting to the effectiveness of the intervention. The fact that skills were not
maintained post intervention may point to a need for a longer period of support in order to firmly
establish the behaviours.

Keywords: Augmentative and Alternative Communication (AAC); aided language input;

augmented language output; caregiver training; child; communicative turns; complex
communication needs, contingent responding; cultural stakeholder; modelling; offering
communication opportunities; social validity.

xix
 Chapter 1: Problem Statement and Rationale

CHAPTER 1
PROBLEM STATEMENT AND RATIONALE

1.1 Introduction
This chapter provides an outline of the problem that is addressed in this study, the
rationale for the study and the significance of this study. Furthermore, this chapter provides
definitions of the terms and a list of abbreviations used in the thesis. In addition to that, an
outline of the chapters is provided.

1.2 Problem statement and rationale

Children with complex communication needs (CCN) present with significant speech,
language and communication difficulties. They encounter challenges, such as the inability to
express their needs and wants, express their emotions, make requests, protest and have social
interaction with the people around them (Beukelman & Light, 2020; Drager & Holyfield, 2016;
Drager, Light, & McNaughton, 2010). They also typically face various challenges that can have
life-long detrimental effects. Their communication challenges may result in difficulties forming
basic social relationships within their family and within their communities; and they may
experience restrictions and/or limitations when participating in activities related to community
living and family life. Furthermore, due to their limited communication skills, children with
CCN of school-going age are often denied the opportunity to participate in educational settings,
including mainstream and special education (Human Rights Watch, 2015; Light & McNaughton,
2015). There is a strong evidence base that children with CCN can benefit from augmentative
and alternative communication (AAC), as a method of improving various communication skills
as a basis for more active participation in all spheres of life ( Beukelman & Light, 2020; Crowe
et al., 2022; Light & Drager, 2007; Romski et al., 2015; Romski & Sevcik, 1997) .
This project was conceived during my work supervising final year speech-language
therapy and audiology (SLP&A) students at rural public hospitals in Limpopo and the North-
West provinces. As a speech-language therapist (SLP), an observation was made of the services
rendered through the public health system to preschool-aged children living with CCN and their
families; and I caught sight of the need to develop new models of delivering AAC intervention to

1
 Chapter 1: Problem Statement and Rationale

this population. I then decided to target Vhavenda caregivers and their children living in the
Vhembe district in Limpopo as I originate from there and this was in line with observations made
and motivated by the proverb that says: “Charity begins at home”.
In the North West and Limpopo provinces, as in the rest of South Africa, children with
CCN, whose caregivers cannot afford private healthcare, receive pediatric rehabilitation services
free of charge through the public healthcare system (Rowe & Moodley, 2013). In my
observations, the services offered to these children and families are extremely limited and also
not always appropriate. This is due to a number of factors that have also been noted in the
literature globally. Many of these factors are specific to the South African public health context,
while others are observed more widely. The factors include (a) the limited number of
professionals trained in AAC, specifically in low and middle income countries (LMICs) and also
in the South African context (Dada, Kathard, et al., 2017; Dada, Murphy, et al., 2017; Fuller et
al., 2009; Pillay et al., 2020); (b) limited or no access to AAC materials and resources in LMICs
including South Africa (Fuller et al., 2009; Gona et al., 2013; McAllister et al., 2013; Tönsing et
al., 2018; Van Niekerk et al., 2017); (c) high caseloads in the South African public health system
leading to SLPs’ infrequent contact with service recipients (Saloojee et al., 2006), thus, children
and caregivers typically attend therapy only once a month or once every second month; (d)
inaccessibility of service locations to rural populations in South Africa due to distance and
transport fees and/or availability (Grut et al., 2012; Kathard et al., 2011; McKenzie & Müller,
2006; Ned et al., 2017; Thomas, 2016; Uys, 2009); (e) service delivery models in the South
African public health system that emphasise individual one-on-one therapy with limited
caregiver involvement (Samuels et al., 2012); and (f) lack of access to SLP services (including
AAC services) that are contextually and linguistically appropriate and culturally sensitive in the
South African health system due to the mismatch between SLPs’ language and culture (mostly
first language Afrikaans and English speaking whereas families speak an African language)
(Barratt et al., 2012; Dada et al., 2017; Kathard et al., 2011; Romski et.al, 2018; Rowe &
Moodley, 2013; Tönsing et al., 2018; van Dulm & Southwood, 2013). It became clear that there
is a great need to offer more appropriate AAC intervention services to children with CCN and
their families.

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 Chapter 1: Problem Statement and Rationale

Training caregivers to implement AAC with their children with CCN in home and
community contexts has been shown to be an effective way to improve child communication
outcomes(Gona et al., 2013; Granlund et al., 2008; Thunberg et al., 2009). An increasing
number of studies over the past few years have shown that caregivers trained in AAC
implementation can successfully facilitate the use of AAC with their children, resulting in, for
example, more frequent communicative turns (Kent-Walsh, Binger, & Malani, 2010a; Nunes &
Hanline, 2007; Rosa-Lugo & Kent-Walsh, 2008), increased requesting using AAC (Gevarter et
al., 2021; Suberman et al., 2020), and using AAC to express multi-symbol messages during story
book reading (Binger et al., 2008). Training caregivers to implement AAC is also congruent with
a paradigm shift in pediatric rehabilitation services that suggests there is a need to facilitate
change in real-life contexts, and to focus on the transactional process of interaction (King et al.,
2018). The Transactional Model of Development that was initially developed by Sameroff and
Chandler in 1975, which was subsequently highlighted in Sameroff and Fiese (2000),
emphasizes the aforementioned paradigm shift, and will form a conceptual cornerstone of this
study. This model views child development as a product of the constant transactions between the
child and the experiences provided by the family and the context (Sameroff, 2013, 2017;
Sameroff & MacKenzie, 2003). Caregiver-mediated communication interventions acknowledge
this concept and are grounded on it. These interventions have become more popular in the past
20 years have been used in the field of AAC (Kent-Walsh et al., 2015; Smith & Hustad, 2015).
The implementation of AAC in LMICs with diverse cultural and linguistic groups has
received increasing attention in the past few years (Muttiah et al., 2015). However,
experimentally controlled studies that document the effect of caregiver training in these contexts
are missing. The aim of this study was therefore to develop and evaluate a culturally and
linguistically appropriate AAC caregiver training programme designed for Vhavenda caregivers
of young children living with CCN. This programme will enhance the current service delivery
model for children living in rural areas by using a caregiver-mediated AAC intervention
approach.

1.3 Terminology
The following terms are used frequently in this study and therefore defined.

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 Chapter 1: Problem Statement and Rationale

1.3.1 Augmentative and alternative communication (AAC)

This refers to the communication methods that are used to augment and/or replace speech
for individuals with CCN (Beukelman & Light, 2020; Bornman & Tönsing, 2016). Children with
CCN typically require AAC to express themselves, while some may need AAC to also augment
comprehension of the spoken language in addition to augmenting their expressive language
(Beukelman & Light, 2020; Romski et al., 2015; Sennott et al., 2016)

1.3.2 Caregiver
This describes a parent or someone other than the parent who is taking care of the child
and who is responsible for carrying out care-giving tasks on a daily basis (Department of Justice:
Children’s Act 38 of 2005).

1.3.3 Caregiver-mediated communication interventions

These are therapeutic approaches that involve the training of caregivers (including
parents) to adapt their communication style in order to be responsive to their children with CCN.

1.3.4 Caregiver training

Intervention where caregivers (including parents) acquire parenting skills (Kaminski et
al., 2008). It aims at giving parents or helping them build relationships with their children.

1.3.5 Communicative turn

A communicative turn is taken when the child transmits a message that is directed
towards the caregiver, for example when the child vocalizes in response to the caregiver; or uses
eye gaze towards an activity or object and then to the caregiver; or uses gestures to respond to
the caregiver; or touches or leans towards the caregiver or smiles at the caregiver (Kent-Walsh et
al., 2010; Muttiah et al., 2018; Rosa-Lugo & Kent-Walsh, 2008).

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 Chapter 1: Problem Statement and Rationale

1.3.6 Child using augmented output

The number of times a child independently points to a picture on the communication
board. The child can point to the symbols on the communication board in various ways such as
pointing using their hands or fingers or using their caregiver’s hand instead (Romski et al.,
2010).

1.3.7 Contingent responding

A contingent response entails any action from the caregiver (verbal or nonverbal) that
indicates that the caregiver has taken note of the child’s communication act and has either
understood it and responds promptly and appropriately to it verbally or non-verbally, or,
alternatively, seeks clarification if the caregiver has not understood it (Broberg et.al, 2012). The
caregiver can make a comment in response to the child’s communicative attempt or
communicative actions, ask the child questions, direct a question to the child for clarity if the
caregiver does not understand what the child wants, or the caregiver can comply with the child’s
request for action or for an item (Broberg et al., 2012; Shire et al., 2016; Yoder & Warren, 1999).

1.3.8. Cultural stakeholder

They are defined as persons who have knowledge about the culture of Vhavenda
regarding beliefs about communication disability, parent child interactions as well as those who
have experienced the culture through the lenses of their communities. This was custom
conceptualised for this study.

1.3.9. Modelling aided language input

This occurs when a communication partner points to a specific graphic symbol on the
communication board while at the same time saying the word or phrase which the symbol
represents (Borgestig et al., 2017; Dada & Alant, 2009; Dada et al., 2019; Jonsson et al., 2011).

1.3.10. Offering communication opportunities

Communication opportunities have been defined as situations where the communication
partner intervenes purposefully to require and ensure a communication response from the

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 Chapter 1: Problem Statement and Rationale

individual with CCN. The communication partner creates an opportunity for the individual with
CCN to respond appropriately and communicate what they need (Sigafoos, 1999).

1.3.11. Social validity

This is the degree to which the goals, procedures, and outcomes of a specific intervention
(in this study a training programme) are regarded as acceptable, appropriate and valuable by
stakeholders (i.e., recipients of interventions and also indirect stakeholders) (Snodgrass et al.,
2022).

1.3.12. Training program

A structured approach to training that can include the use of manuals, role playing, video
vignettes and homework (Kaminski et al., 2008).

1.3.13. Vhavenda
They are an ethnic group in South Africa living mostly near the South African-
Zimbabwean border. They speak Tshivenda as a first language which is one of South Africa’s
eleven official languages.

1.4. Abbreviations
AAC : Augmentative and alternative communication
app : Application
ASD : Autism Spectrum Disorder
CAQDAS : Computer Assisted Qualitative Data Analysis Software
CCD : Caregiver-child dyad
CCN : Complex communication needs
CCT : Child communicative turns
CgTP : Caregiver training programme
CR : Contingent responding
CuAO : Child using augmented output
DD : Developmental disabilities

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 Chapter 1: Problem Statement and Rationale

CP : Cerebral palsy
DV : Dependent variable
FCI : Family centred intervention
HPCSA : Health Professions Council of South Africa
ID : Intellectual disabilities
IOA : Inter-observer agreement
IV : Independent variable
LMICs : Low- and-middle income countries
MACS : Manual ability classification system
MALI : Modelling aided language input
Mini MACS : Mini manual ability classification system
NAP : Non-overlap of all pairs
OCO : Offering communicative opportunities
PCS : Picture communication symbols
PMLD : Profound and multiple learning difficulties
PND : Percentage of non-overlapping data
RA : Research assistant
RCTs : Randomized control trials
SCED : Single Case Experimental Design
SMC : Synthesized member checking
SLP : Speech-language therapist (this also includes those with dual registration -
Speech-Language Therapist and Audiologist. In South Africa, dual
qualification and registration was common until relatively recently when
speech therapy and audiology programmes were separated).
VFCS : Visual function classification system

1.5. Models for developing interventions

This study was conceptualised using a phase-based research model for developing
interventions. The design and development (D&D) model by Thomas and Rothman (1994) was
applied in this study and discussed in detail in Chapter 6 (Development phase). The study was

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 Chapter 1: Problem Statement and Rationale

further guided by the steps in intervention research as outlined by Fraser and Galinsky (2010)
wherein their steps were routed in the D&D model. The steps in intervention research include:
(a) developing a problem and program theories; (b) designing program materials and measures;
(c) confirming and refining program components using efficacy tests; (d) testing the
effectiveness of the program in different settings; and (e) disseminating the program findings and
materials.
1.6. Outline of chapters
This thesis is presented in 10 chapters. Chapter 1 provides the problem statement and
rationale for conducting this study. Furthermore, definitions of terms used in the study and
abbreviations are also outlined in this chapter.
Chapter 2 provides the literature review and conceptual framework of the study. This
chapter discusses research findings on the significance of the theories in child language and
communication development; the challenges that children with CCN experience; the significance
of AAC for children living with CCN; caregiver training in AAC; culturally and linguistically
appropriate AAC; AAC intervention services in the South African context and a discussion of the
conceptual framework.
An overview of the methodology of the three-phased study is presented in Chapter 3
commencing with the aims, study paradigm, and overall design used. This study made use of an
exploratory sequential mixed method design with three phases. The overview of the research
designs for the exploratory phase (Phase 1), development phase (Phase 2) and the evaluation
phase (Phase 3) is highlighted, although they are discussed fully in the chapters that follow.
Chapter 4 outlines the first sub-study of Phase 1, during which a scoping review of
studies focused on AAC caregiver training was undertaken. This chapter outlines the aims, sub
aims, methodology and the results of the review. Furthermore, the alignment of the caregiver
training approaches with characteristics of effective parent training is discussed. To conclude this
chapter, implications of the scoping review for the development phase are discussed.
The second sub-study of Phase1 comprised of interviews with cultural stakeholders and
these are discussed in Chapter 5. The cultural stakeholder interviews were done to identify the
cultural practices of Vhavenda with regards to caregiver-child communication interaction, as
well as their beliefs about children with a communication disability; and to determine

8
 Chapter 1: Problem Statement and Rationale

acceptability of the proposed programme strategies for the target population. The aim, sub-aims,
methods and results are discussed, as well as the implications of the results for the development
phase.
The development phase of this study is presented in Chapter 6 where the design,
development, expert review and piloting of the custom-made caregiver training programme and
associated materials will be discussed. The discussion includes the aims, sub-aims, theoretical
underpinnings for the development of the programme, and input from the exploratory phase
towards development of the custom-made caregiver training programme. The content of the
programme, the training materials developed, as well as all materials developed to measure the
effect of the programme are described. Changes made after the expert review and the pilot
investigation are also described.
Chapter 7 outlines the methodology of the evaluation phase of this study with regards to
the aims, sub-aims, and stages of the phase as well as the design used. The operational
definitions of the dependent variables are provided. Thereafter, the chapter highlights sampling,
selection and description of the participants. The additional materials (not described in Chapter
6) and procedures used to deliver the caregiver training programme are also discussed.
Furthermore, the procedures for collecting data on the five dependent variables during baseline,
intervention and maintenance probes are discussed. The data analysis procedures are explained.
Factors influencing the validity and reliability of the research are described, and ethical
considerations are discussed.
The results of the evaluation phase are described in Chapter 8. The results are presented
according to the sub-aims for this phase of the study. The effect of the training programme on
five dependent variables (three caregiver variables and two child variables) for each of the
caregiver-child dyads is presented using a graph. Visual analysis of each dependent variable is
described according to changes within conditions and across conditions in trend, level and
stability or variability. Effect sizes are provided (non-overlap of all pairs) with accompanying
confidence intervals.
The discussion of the results will be presented in Chapter 9. The effects of the caregiver
training are discussed according to the caregiver and child variables and then compared to other

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 Chapter 1: Problem Statement and Rationale

studies that measured these variables. The possible reasons for the differences and similarities
are also discussed.
In Chapter 10, which is the conclusion, a summary of results is provided and their
clinical implications are discussed. The strengths and limitations of the study are also discussed.
The chapter ends with recommendations for future research.

1.7. Summary
This chapter provided an outline of the problem that is addressed in this study, the
rationale for the study and the significance of this study. Definitions of frequently-used terms
were given, as well as a list of abbreviations used in the thesis. In addition to that, an outline of
each chapter was provided.

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 Chapter 2: Literature Review

CHAPTER 2
LITERATURE REVIEW
2.1 Introduction
This chapter provides a review of literature that is relevant to the current study. First,
theories on language and communication development are reviewed, and Vygotsky’s
sociocultural theory is highlighted as a theoretical cornerstone of the study. The literature on
children with CCN, AAC for children with CCN, and caregiver training to improve
communication of children with CCN is reviewed next. Thereafter, the notion of culturally and
linguistically appropriate AAC is introduced, followed by a description of AAC intervention
services in the South African context. Lastly, the conceptual framework of this study is
introduced.

2.2 Language and communication development

Communication is central to our human existence and has been described as “the essence
of human life” (Light, 1997, p. 61). According to the International Classification of Functioning,
Disability and Health (ICF) (World Health Organization, 2001), communication is one of the
nine major life areas that form part of regular and necessary activities in which humans
participate. A major achievement of childhood is the acquisition of communication skills,
including the acquisition of language. Within the first few years of life, children’s
communication skills change as pre-intentional behaviours (e.g., reflexive crying) become
intentional, and as the child learns to use more conventional symbolic behaviours, that culminate
in the use of a sophisticated abstract conventional code (language) that enables the exchange of
decontextualized novel meanings with their communication partners (Bates et al., 1979;
Rowland & Fried-Oken, 2010). As a point of departure, it would be an oversight not to
acknowledge the significance of theories pertaining to typical language and communication
development as they underscore the importance of relationships that exist between individuals
and context and how this relationship influences communication and language learning. Thus,
the theories that form the foundation for this research stem from the fields of language and
psychology.

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 Chapter 2: Literature Review

It is apparent in the theories that will be discussed that the caregiver-child relationship is
interactional wherein there is co-construction of meaning and influences between both parties
that are bi-directional in nature. These interactions form the basis for cognitive, emotional and
language development. The theories that inform language development include nativism
(Chomsky, 1975), constructivism (Piaget, 1964; 1972), behaviourism (Skinner, 1985; Watson,
1924), Vygotsky’s (1962) language acquisition theory and sociocultural theory, as well as the
transactional model (Sameroff & Fiese, 2000) of development.
The nativist perspective (Chomsky, 1975) entails the view that children are born with the
ability to learn language as the features of language and grammar are innate. Though language is
said to have universal features and/or parameters that are abstract, it is believed that that these
features cannot be transferred from an adult to a child through imitation and communication.
Contrary to this theory, the constructivists are of the belief that cognition precedes language
development (Piaget, 1964; 1972). They believe that language is a manifestation of an
individual’s emotional and cognitive abilities to talk about the world, others and self. They argue
that the linguistic rules based on nativism are complicated and abstract, thus, they aim to give
clarity to the structure of the sentence and do not take into consideration the meaning and role
the adult in transferring the language features. Therefore, Piaget and his colleagues in (1962) put
emphasis of the role of cognition in language development rather than the innateness of one’s
ability to learn language. Piaget and colleagues saw language as an outcome of the interplay of
the child’s interaction with the environment; the interaction between cognitive perceptual
abilities and language experience. What an individual learns about language is determined by
what they have learned in the environment. A child is seen an active learner in the environment,
who creates complex intellectual structures in order to problem solve independently.
Behaviourists (Skinner, 1985; Watson, 1924) agree to a certain extent with the
constructivists regarding the role of the environment in changing behaviour, as speaking a
language is viewed as a skill-like behaviour. Children learn language from their experiences with
the environment. The behaviourists emphasize that there is a stimuli-response relationship that
exists; thus, the child reacts to a stimulus in the environment, and this response is then
conditioned by reinforcement. When the child initiates some form of communication, the adult is

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 Chapter 2: Literature Review

bound to respond and vice versa. When there is a response, the stimuli can be deduced; and given
the stimuli, the response can be predicted.
With all these differing views from the different schools of thought, it can be concluded
that neither innate language abilities of the child nor environmental exposure alone can explain
language development; both aspects play a role as does cognition and thought. This is also
reflected in Vygotsky’s sociocultural perspective (1962) wherein he posits that language
development (and human development in general) is a socially and culturally mediated process
(Renner, 2003). More knowledgeable members of the community interact with the developing
child, and scaffold the acquisition of culturally valued skills, and the development of language
and cognition, by modelling the ‘ideal form’ (mature form) of a behaviour to the child. As the
child’s abilities and skills change, the more knowledgeable partner (parent, sibling, or other)
adjusts their behaviour to foster increasing independence (e.g., a toddler who can walk will not
be constantly carried any more).
The range of vocabulary development is dependent on the social contexts and language
resources available for the child in their culture. Children belong to a culture; regardless of where
it takes place and how it unfolds, interaction is always a social and cultural process. Thus, the
child’s sociocultural experiences occur through language and lead to thought development.
The child’s zone of proximal development plays a vital role in their learning. Learning is
achieved through the help of others. The child has the potential to problem solve while guided by
others. The competent partner plays a significant role in the child’s learning and helping them
achieve their full potential. Therefore, language is social and dependent on the context.
This view aligns with transactional model (Sameroff, 2000) of development, as child
development is viewed as a product of the dynamic continuous interactions between the child
and the experiences provided by the family and the context. This model embeds a child in an
environment of social relationship with the expectation that this will amplify and minimize
certain of the child’s characteristics. The experiences provided by the environment are not
viewed as independent of the child. The child could be a strong determinant of their current
experiences; however, developmental outcomes cannot be attributed without an analysis of the
effects of the environment on the child. Sameroff and Chandler (1975) mention that children
with high-risk births end up with later developmental problems, not because of the biological

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 Chapter 2: Literature Review

damage to the brain but because of the negative effects these children have on their caregivers.
How the child behaves is seen as a function of how the environment reacts, rather than as a
function of what is intrinsic to the child.
The responses from the environment therefore facilitate the child’s development.
Caregiver responsiveness is reported to take on different forms in different cultures; however, it
has been observed in a variety of Eastern, Western, and African cultures. Researchers have noted
cross-cultural ‘universal’ aspects but also culture-specific manifestations (Tamis-Lemonda et al.,
2014). Caregiver responsivity (or caregiver contingent responding) has been investigated as a
possible influencing factor on child language and communication development (Tamis-Lemonda
et al., 2001; 2014). In European American families, maternal responsiveness has been found to
predict the child’s learning of new words and promote communication. Specifically, maternal
responsiveness has been found to predict the vocabulary; diversity of communication skills and
other language skills in children who use speech for communication (Tamis-Lemonda et al.,
2001). Thus, children of extremely responsive mothers develop language and communication
earlier than those of minimally responsive parents. Tamis-Lemonda et al. (2014) theorise that
responsiveness fosters a young child’s understanding of the intentionality of communication
interactions as their behaviour is responded to and treated as meaningful by others. The temporal
continuity, contingency, informative nature and multimodality of contingent responses are further
believed to scaffold vocabulary acquisition.
Care must be taken in applying such findings across cultures. It would be amiss to
assume that caregiver responsivity is identical in form and has identical purposes across cultures;
likewise, it would be amiss to assume it has no role to play in some cultures. In this regard,
Morelli, Quinn et al. (2018) observed that, across cultures, the mother may not necessarily be the
person who primarily talks to the child, as peers, siblings and other competent members of the
culture may fulfil this function. Likewise, these authors note that maternal responsivity may take
on non-verbal forms and achieve the primary purpose of socialising the child into a relational
sense of self (i.e., to help the child see themselves as part of a community and be cognizant to the
roles and expectations of themselves in this community) rather than teaching the child
vocabulary. It is of vital importance to respect and acknowledge such cultural differences,
especially when some form of support or intervention is to be provided to families of children

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 Chapter 2: Literature Review

with communication disabilities (Morelli, Bard et al., 2018). It is far too easy to assume Western-
centric models of service delivery that annihilate valuable cultural child rearing conventions by
replacing them with culturally-incongruent but ostentatiously ‘better’ ways of interacting with
children. A deep and respectful engagement with cultural stakeholders, acknowledging their
competence and the legitimacy of culturally-rooted child rearing practices is necessary to avoid
culturally-incongruent forms of service delivery (Morelli, Bard, et al., 2018; Morelli, Quinn, et
al., 2018).
This is in line with the eco-cultural theory that alleges that the family is responsible for
socially constructing the child’s activity settings so as to accommodate the needs of children
within the family environment (Bernheimer et al., 1990). Furthermore, the theory posits that
family members are more likely to implement and sustain interventions that fit into their daily
routines and those that yield positive outcomes for the family as a whole, as well as those that are
in line with the parent’s objectives and beliefs. The components of the eco-cultural theory are
necessary to incorporate in intervention planning because it increases the “contextual fit”,
meaning that interventions for young children should fit into their daily routines and that of the
of a family and be incorporated therein (Brookman-Frazee, 2004). Interventionists need to build
on the strengths of the family and what the family is already doing rather than bringing in new
concepts and forcing them onto families because these new concepts might not build on their
strengths and what they know. The concepts might not be culturally appropriate and contextually
relevant. This might lead to interventions not being accepted by the families they are intended
for.

2.3 Children with complex communication needs

Speech, language and communication are fundamental to participation, development and
well-being (McCormack et al., 2009). When speech, language and/or communication are
impaired, reading, writing, education, employment and forming social relationships are affected
negatively. Children with CCN present with significant speech, language and communication
difficulties. These communication difficulties are typically concomitant with congenital
neurodevelopmental disorders such as autism spectrum disorders (ASD), cerebral palsy (CP),
multiple and severe disabilities and cognitive impairments, but may also be caused by acquired

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 Chapter 2: Literature Review

disorders such as traumatic brain injury (Communication Matters UK Glossary, 2017). Children
living with CCN encounter challenges such as the inability to express needs and wants, express
their emotions, make requests, protest and have social interactions with people around them
(Beukelman & Light, 2020; Drager et al., 2010). They also encounter various challenges that can
have lifelong detrimental effects. Their communication challenges may result in difficulties
forming basic social relationships within their family and within their communities; put them at
risk for abuse; and they typically experience restrictions and/or limitations when participating in
activities related to community living and family life (Light & McNaughton, 2015).
Furthermore, due to their limited communication skills, children living with CCN who are of
school-going age are often denied the opportunity to participate in educational settings, including
mainstream and special education (Human Rights Watch, 2015; Light & McNaughton, 2015;
McCormack et al., 2009), resulting in limited opportunities to find employment as adults (Light
& McNaughton, 2015).
Viewed through the lens of sociocultural theory (Vygotsky, 1962), the reaction by the
environment to children with CCN can result in additional impairments in social functioning. For
example, the creation of special environments leads to social segregation because the child is
regarded as different (Renner, 2003). This has a more detrimental effect on the mental
development of the child than the disability itself. For this reason, Vygotsky advocated for
normal treatment and social contact for children with disabilities. Thus, always putting the
individual before the impairment. As a result, impairment becomes a normal state for that person.
When children living with CCN are treated differently from other children, the typical
process of enculturation is affected and this affects mastery of cultural tools, higher mental
functions and cultural forms of behaviour. The psychological development may also follow a
different course from the typical one, as opposed to following the typical path at a slower pace.
Therefore, the consequences of the impairment are influenced by attitudes and adaptations made
by the social environment.
In line with transactional theory, child and caregiver behaviour influence each other over
time. A child who communicates less and does not initiate or respond to communication from the
caregiver, will often induce less responsive behaviour from the caregiver. A study by Slonims et
al., (2006) for example, showed that 8-week-old infants with Down syndrome were less

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 Chapter 2: Literature Review

communicative than infants without disabilities, yet their mothers were as responsive as mothers
of infants without disabilities. However, their mothers were significantly less responsive when
the infants were 20 weeks of age. This demonstrates the bidirectional influence of the child on
the caregiver and vice versa, and that the reaction from the environment can lead to less than
optimal developmental conditions for a child with CCN.
On the other hand, the effects of impairment on functioning can also be minimised by
constructive reactions from the environment (Renner, 2003). The theory suggests that there is a
relationship that exists between personal traits and development of mental abilities of children;
and their relationship with significant others (in this case, the parent or caregiver). When a child
with disabilities interacts with a competent member of a particular culture, who could be an older
child or an adult, the social environment affords the child with a developed model of culturally-
valued skills and abilities.
For the optimization of development and overcoming disability, it is essential to create
developmental side-tracks of enculturation. This includes substituting functions by other
functions, thus preparing collateral pathways which open new possibilities of development for
the child with disabilities. For children living with CCN, their communication and language side-
tracks can therefore be created by employing the use AAC.

2.4 AAC for children with CCN

There is a great deal of stress and frustration encountered by the child and caregiver
where there is miscommunication and communication breakdown. To mitigate for the
miscommunication and effects they have on communication, AAC intervention should be
employed as it influences communication development of children living with CCN and
developmental disabilities (DD) (Branson & Demchak, 2009).
AAC refers to the communication methods that are used to augment and/or replace
speech for individuals living with CCN (Beukelman & Light, 2020; Bornman & Tönsing, 2016).
Thus, AAC offers children living with CCN a different or additional way of communicating and
thus supports communication and language development (Romski et al., 2015). The United
Nations Convention on the Rights of Persons with Disabilities (Convention on the rights of the
child, 2006). Children’s Charter states that communication is important for all children and that

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 Chapter 2: Literature Review

they have the right to communicate using their own preferred means of communication, which
includes AAC. AAC provides access to wider vocabulary and language (Pennington et al., 2018).
It has also been reported to improve turn-taking skills, commenting, mean length of utterance,
phonological awareness, reading and writing skills (Light & McNaughton, 2012). Additionally,
AAC has been reported to reduce challenging behaviour in children who experience frustration
due to their inability to communicate (Beukelman & Light, 2020; Light & McNaughton, 2012).
In a recent mega-review, Crowe et al. (2022) identified 84 systematic reviews, literature reviews
and meta-analyses summarizing the effects of AAC interventions for children with DD and
intellectual disabilities (ID) on their receptive and expressive communication. On the basis of the
results from these records, various AAC interventions (e.g., Picture Exchange Communication
System, high-tech AAC, and aided AAC modelling) have been found to effectively improve
children’s communication skills. Branson and Demchak (2009) systematically reviewed the
evidence base of AAC for use with infants and toddlers with disabilities. Positive effects in the
areas of functional communication skills, challenging behaviour, speech production, receptive
and expressive language skills were highlighted. Light and Drager (2007) also reported that
improvement can be seen when multi-modal forms of communication are used. The fundamental
goal of AAC intervention is for children to live happy and fulfilled lives; for children to realize
their full potential in communication and participate fully in their communities, educational and
social contexts (Light & McNaughton, 2015; Soto & Yu, 2014).
Children living with CCN typically require AAC to express themselves while some may
additionally need AAC to also augment comprehension of spoken language (Romski et al., 2015;
Sennott et al., 2016). AAC can be categorized into aided (uses external devices) and unaided
systems (utilizes the body of the individual only). Both aided and unaided systems can increase
access to a variety of communication partners and contexts. Aided systems, and particularly
those with voice output (i.e., speech generating devices (SGDs) typically allow more easily for
communication with unfamiliar partners, whereas unaided systems require use with partners who
are familiar with that mode. Unaided systems require the person who uses AAC to remember
how to form the symbols (i.e. signs) accurately (Bornman & Tönsing, 2016). Aided systems, on
the other hand, require that an aid (e.g., communication board, SGD) be available for use, and
this is not always practical or possible in all situations and contexts. The main principle of using

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 Chapter 2: Literature Review

AAC is that it should always be multimodal, and include both aided and unaided systems for
each individual, in order to have communication methods available for a variety of partners and
contexts.
At the same time, care needs to be taken to build on and encourage existing
communication methods. Since communication is a ‘two-way street,’ communication partners
significantly contribute to the success or failure of joint interactions (Naraian, 2010). A close
collaboration between familiar communication partners is needed, as familiar partners are often
able to identify existing communication skills accurately. Conversely, frequent communication
partners such as caregivers may also need assistance in identifying, interpreting and responding
consistently to the child’s communication attempts in order for them to create communication
opportunities (Douglas et al., 2017; Gona et al., 2013; Ogletree et al., 2011; Sigafoos, 1999).
Caregivers are typically amongst the first and most important communication partners of young
children ( Kaiser & Roberts, 2013).

2.5 Caregiver training to improve communication of children using or in need of AAC

As discussed in Section 2.2, the environment plays an important role in language and
communication development of the child. The family or extended family in particular provides
an important environment for language and communication development of the young child. A
child continues to search for connections between the reactions of the environment and their own
actions as well as events in the environment. Communication development with alternative
means also needs to be supported by the environment (Renner, 2003).
Congruent with the paradigm shifts from professional-led, clinic-based early intervention
services to family-centred intervention (FCI) ( Dunst, 2002), AAC intervention programs for
young children have also recognized the importance of a family-centred approach (Granlund et
al., 2008; K Mandak & Light, 2018). Family-centred intervention focuses on building the
capacity of caregivers and interaction partners to provide for the needs and support the
development of their children (Dunst et al., 2014). It is also grounded in the belief that, when
afforded appropriate and customized support from interventionists, caregivers and interaction
partners of children with disabilities have the capacity needed for stimulating their child’s

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 Chapter 2: Literature Review

development (Dunst et al., 2014; Ingber & Dromi, 2010; Maluleke et al., 2021). As noted before,
who these caregivers and interaction partners are, may differ between cultures.
Teaching caregivers and interaction partners to include language-enhancing strategies in
daily routines may offer children learning opportunities in their natural environment and daily
routines, thereby allowing for authentic learning experiences and greater generalization of
children’s language skills (Bornman et al., 2020; Ann P Kaiser & Roberts, 2011). Furthermore,
interventions that are conducted in a family-centred manner may result in benefits for caregivers,
such as reduced stress and anxiety, better psychological welfare, increased caregiver knowledge,
as well as improved self-efficacy and proficiency in carrying out intervention (Bailey et al.,
2012; Carnes, 2012; King et al., 2017). A further benefit of focusing on caregivers is that
caregiver-child interactions can improve, which positively impacts the family’s quality of life
(King & Chiarello, 2014).
Caregiver-mediated communication interventions acknowledge the transactional nature
of caregiver-child interactions. These interventions, which have become more popular in the past
20 years, have been used in the field of AAC (Kent-Walsh, Murza, Malani, & Binger, 2015;
Smith & Hustad, 2015). Caregiver-mediated AAC interventions are founded on the assumption
that caregivers and partners who interact frequently with the child should play a central role in
the intervention of young children, as they are present in the contexts within which the children
live, interact, learn, and play (Granlund et al., 2008). They are also essential communication
partners for young children (Ferm et al., 2011). While the primary female caregiver often plays a
prominent role in this regard in Western culture, peers, siblings and the extended family and
community may play a more prominent role in some non-Western cultures (Geiger & Alant,
2005; Morelli, Quinn et al., 2018). Several programs aimed at training caregivers to implement
AAC strategies with their children with complex communication needs have been developed and
reported in the literature (Adamson et al., 2010; Ferm et al., 2011; Kent-Walsh & Binger, 2015),
and two reviews have been published on communication partner training programmes.
Kent-Walsh, Murza, Malani and Binger (2015) conducted a meta-analysis aimed at
determining the overall effects of partner instruction on the communication of people who use
AAC; and whether the outcomes were influenced by any moderating variables that relate to the
participants, intervention and outcome characteristics. Of the studies included in the meta-

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 Chapter 2: Literature Review

analysis, seven involved training caregivers as communication partners. Studies that employed
experimental designs such as randomized controlled trials (RCTs), quasi-experimental and
single-case experimental designs were included. The authors concluded that there is strong
evidence for the effectiveness of communication-partner instruction on improvements in the
communication of the person using AAC, with the strongest evidence being for children under
the age of 12 years.
A systematic review by Shire and Jones (2015) included four additional studies on
caregiver training (Cafiero, 1995; Chang, 2009; Iacono et al., 1998; Romski et al., 2010). This
review included experimental group designs, and not only single-case experimental designs
(SCEDs). In addition, the authors also included grey literature (e.g., unpublished dissertations).
Mixed results were reported for caregiver and child outcomes (i.e., the mean length of utterances,
communication turns, caregiver utterances, total caregiver turns, the implementation of
strategies, caregiver-child communication, and the frequency of use of the strategies and skills).
The effect sizes ranged from small to large.
Subsequent to these reviews, a number of additional studies have been conducted on the
effects of training caregivers to support AAC implementation for their children (e.g.,
Alsayedhassan et al., 2020; Douglas et al., 2017; 2021; Suberman & Cividini-Motta, 2020;
Timpe et al., 2021; Treszl et al., 2022). As part of the exploratory phase of this study, a scoping
review of studies reporting on the effect of training programmes aimed at training caregivers of
children to implement AAC was undertaken, and a detailed summary of these studies is provided
in Chapter 4.
Training programmes that have aimed to assist caregivers to scaffold language and
communication development of their children have targeted a number of caregiver behaviours,
including contingent responding (as discussed under Section 2.2), providing appropriate
language models, and encouraging children to take communicative turns by prompting and
environmental arrangements. Roberts and Kaiser, (2011) conducted a meta-analysis on parent-
implemented language interventions and found that responsiveness was taught in 10 of 18
studies, and also measured as a parental outcome in seven studies. Providing general or specific
language models was taught in 15 studies, and measured as an outcome in five studies. Creation

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 Chapter 2: Literature Review

of communication opportunities through, for example, environmental arrangement, was reported

in two studies.
Contingent responding (as discussed under Section 2.2) describes any action from the
caregiver (verbal or nonverbal) that indicates that the caregiver has taken note of the child’s
communication act and has either understood it and responds appropriately to it verbally or non-
verbally, or, alternatively, seeks clarification if the caregiver has not understood it (Broberg et al.,
2012; Shire et al., 2016; Yoder & Warren, 1999). As noted in Section 2.2, caregiver
responsiveness manifests in different forms in various cultures, but has been found to be present
across cultures, and can scaffold communication development as the child comes to understand
the intentionality of communication behaviours and also learns to map the meaning of words by
the caregiver’s contingent responses. As will be seen from the scoping review (Chapter 4),
responsiveness has also been targeted in AAC-focused caregiver training.
Modelling of general and specific language targets provides children with an example of
the communication behaviours they are expected to produce, in line with Vygotsky’s
sociocultural theory (1962). Children who use speech to communicate are typically exposed to
speech on a continuous basis, and, in European American families, have been reported to hear
approximately 26 million words between birth and age 4 (Hart & Risley, 1995). It has been
proposed that children using AAC should also be exposed to models of AAC use by their
partners (Allen et al., 2017; Sennott et al., 2016). Specifically, partners should pair their spoken
language models with AAC. Such modelling (also called augmented input or aided language
input – the latter in case of modelling an aided system) may have a number of benefits for
children learning to use AAC. Firstly, such models can strengthen the receptive language
foundation as the augmentation of speech by another mode can strengthen the salience of the
message meaning (Allen et al., 2017, Dada, Flores, et al., 2017; Dada, Murphy, et al., 2017).
Secondly, such modelling reduces the input-output asymmetry that children using AAC typically
experience, where they hear spoken language but are expected to express themselves in an
alternative modality (Sennott et al., 2016). When adults provide language models using AAC to
demonstrate the use thereof, children may imitate these models and also learn to use the system
(Allen et al., 2017). Finally, when using the child’s AAC system, (specifically aided systems with
limited vocabulary options), partners may identify shortcomings of the system and learn to

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 Chapter 2: Literature Review

overcome them (Allen et al., 2017) . Therefore, the systematic integration of AAC into the social
environment by partners also emphasises the acceptability of these methods and contributes the
creation of a communication environment that supports and promotes these methods.
Creating communication opportunities through, for example, environmental
arrangements form an integral part of milieu teaching strategies, a partner-implemented
communication intervention strategy that has been found effective for children with a variety of
language and communication disorders, including those in need of AAC (Kaiser et al., 2001;
Kaiser & Wright, 2013; Yoder & Warren, 2002; Yoder & Stone, 2006). Environmental
arrangements entail setting up the environment in such a way that children are enticed to
communicate, for example, by offering them choices or making a desired item visible, but
inaccessible without help. While responsivity and modelling may be observed in the inactions
between children without disabilities and their more competent partners, environmental
arrangements are arguably more purposeful strategies that may be helpful when children do not
acquire communication adequately through routine interactions.

2.6 Culturally and linguistically responsive AAC service provision

Like other fields of allied health, the field of AAC has its roots in Western scientific
models and values (Muttiah, Gormley et al., 2022; Pillay & Kathard, 2018; Tönsing & Soto,
2020). An increasing number of authors and researchers have critiqued the limited
acknowledgement of a Western and Anglo-centric bias in the field. For example, authors have
reported limited cognizance of bilingualism and limited recognition of the home language in
AAC interventions (Stone, 2019; Soto & Yu, 2014; Tönsing & Soto, 2020; Tönsing et al., 2018;
2019). Thus, interventions are still carried out in one language instead of recognising
multilingualism (Tönsing & Soto, 2020). Furthermore, there is still a paucity in research which
then affects availability of evidence based interventions for multilingual children. Furthermore,
carrying interventions in one language might neglect the sociolinguistics in multilingual families
(Soto & Yu,2014; Tönsing & Soto, 2022).
Also, the way in which AAC interventions are conceptualised and implemented does not
always respect cultural customs and values around communication (Dada et al., 2017; Kulkarni
& Parmar, 2017). Most of the aided AAC systems available do not cater for the multilingual and

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 Chapter 2: Literature Review

multicultural context of South Africa. The common picture-based communication symbols do

not cater for some of the commonly used words found in South Africa such as a symbol for
“pap” (maize porridge), thus making the symbols not congruent with the context of South Africa
(Dada et al., 2013). Furthermore, most SGDs do not allow the AAC user to use different
languages or have an option for a different language on their system. This then poses difficulties
as most South Africans to switch between languages as they move from one context to another.
Most of the text to speech aided AAC devices do not cater for most of South Africa’s indigenous
languages. It is of significance that AAC intervention in the South African context should be
multilingual, because the population is diverse, languages and the contexts are multilingual
(Mccord & Soto, 2004; Tönsing & Soto, 2020; Van Niekerk & Tönsing, 2015). Where culture is
concerned, the majority of the therapist in the public healthcare system that serves majority of
the South African population (Rowe & Moodley, 2013) come from cultural backgrounds the
differ significantly to the population they serve. Thus, it is important for the therapists to exercise
cultural humility (Chang, Simon et al., 2010; Kirby, Spencer et al., 2022; Wright, 2019).
To counteract this bias, authors have called for increased respectful and deep engagement
with persons from diverse language and cultural backgrounds who require AAC, as well as their
families and stakeholders to bring about more respectful, appropriate and meaningful AAC
research and intervention. Qualitative, descriptive and collaborative, participatory methodologies
have been called for in an effort to form respectful partnerships and develop appropriate AAC
resources and models of service delivery that promote agency and respect indigenous knowledge
(Amery et al., 2020; Dada et al., 2022; Kulkarni & Parmar, 2017; Stone, 2019).
With regards to young children in need of AAC from diverse backgrounds, engagements
with caregivers and other stakeholders can foster an understanding of caregivers’ lived reality of
caring for a child with CCN, as well as typical interaction patterns between children and
caregivers, expectations of interventions, views about AAC systems and strategies, and possible
implementation barriers (Gona et al., 2013; Muttiah, Seneviratne, et al., 2022; Pickl, 2011).
These aspects are crucial to consider in AAC interventions for young children from diverse
backgrounds.

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 Chapter 2: Literature Review

2.7 Provision of AAC services in the South African context

South Africa has two healthcare systems; namely the public and private. The public
sector functions on the district health system approach that emphasises primary healthcare (Rowe
& Moodley, 2013). Sixty eight percent of South Africa’s population relies on the public
healthcare sector and only 16% on the private healthcare sector. Consequently, children with DD
and CCN aged 0 - 6 years receive rehabilitation services through the public healthcare system as
the majority of families cannot afford private healthcare (McKenzie & Müller, 2006; Rosenbaum
et al., 2011; Saloojee et al., 2006). Speech-language pathology services are scant in South Africa
and this can be viewed by the results of the World Bank report of 2013 as reported by McAlister
and colleagues. The speech-language therapist (SLP) to client ratio was 1:8000 in the 2013 report
and the number has since risen to 1:2-4 million clients as compared to 1:2400/2500 in developed
countries such as United Kingdom, United States of America, Canada, etc. (Crowley, Baigorri,
Ntim, Bukari, Oseibagyina, et al., 2013; McAllister et al., 2013; Popich et al., 2007). In
agreement with the World Bank report, Pillay et al.,(2020) profiled the South African SLP
workforce. They found that between 2002 and 2017 there were about 2613 therapists registered
in South Africa: some as SLPs (n=1086) and some as both SLPs and audiologists (dual
registration) (n=1527). The demographics showed that the majority of the practitioners were
white, followed by Indians and blacks and most are independent practitioners practicing in the
private sector. This then contributes to the challenges experienced in the public healthcare sector.
These challenges include, but are not limited to, high caseload; limited resources; and the
linguistic and cultural diversity of the population.
There are factors contributing to the high caseloads and these include: (1) communication
rehabilitation services are primarily available in regional and tertiary hospitals that are located in
the cities, far from rural areas where they are also needed (Kathard et al., 2011; McKenzie &
Müller, 2006; Uys, 2009); (2) limited resources and speech-language pathology professionals in
relation to the population in need of the services (Pascoe et al., 2013); and (3) South Africa is a
linguistically and culturally diverse country; however, the majority of professionals trained in
AAC are first language English and Afrikaans speakers and do not speak the first language of
their clients, thus linguistic and cultural sensitivity might be compromised during service

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 Chapter 2: Literature Review

delivery and might lead to low interest in using AAC (Dada, Murphy, et al., 2017; van Dulm &
Southwood, 2013).
South Africa is a multilingual country and has diverse cultures, thus it is described as “a
rainbow nation” coined by the late Archbishop Desmond Tutu in 1994. The diversity in language
and culture poses challenges in offering rehabilitation services, specifically Speech-Language
therapy and AAC intervention. Providing any form of rehabilitation services in LMICs appears
to be a challenge because they are largely constituted by rural areas, and poor performing
economies in LMICs lead to scarcity of resources, materials, AAC technology and limited
healthcare services (Wylie et al., 2013; World Bank, 2012). Some of the challenges related to
AAC provision children with CCN are faced with in LMICs are as a result of: (1) limited number
of professionals who are trained in AAC in developing countries (Fuller et al., 2009); (2) limited
or no access to AAC materials and resources (Fuller et al., 2009; Gona et al., 2013; Wylie et al.,
2013); (3) lack of awareness and knowledge of AAC by people living in rural communities
(Fuller et al., 2009); (4) limited training available for caregivers in AAC (Fuller et al., 2009;
Gona et al., 2013; Muttiah et al., 2015); and (5) limited or lack of access to quality AAC service
provision that are contextually fit, linguistically and culturally sensitive (Barrett & Marshall,
2013; Bunning, Gona, Odera-Mung’Ala, Newton, et al., 2014; Fuller et al., 2009; McAllister et
al., 2013; Muttiah, 2016; Pickl, 2011).
In order to overcome these challenges in AAC intervention, implementation and service
provision in South Africa for children with CCN, researchers have advocated for a paradigm
shift from child-centred interventions to caregiver mediated interventions (Popich et al., 2007).
Caregiver-mediated interventions have proven to be effective because caregiver involvement has
been reported to be indispensable to the success of most AAC interventions (Gona et al., 2013;
Balton, 2004). Balton (2004) reports on 16-week caregiver training intervention called the
parent-child programme that is implemented at Chris Hani Baragwaneth Academic Hospital.
Caregivers bring their children when they go for training. This programme teaches caregivers of
children who are at risk of and those who have been diagnosed with communication disabilities
some skills. The skills include, but are but not limited to communication, communication
facilitation techniques, child development and needs, play, early literacy, having fun with
movement, eating healthy, attention-deficit hyperactivity disorder (ADHD) and self-esteem.

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 Chapter 2: Literature Review

Caregivers who participated in the study reported that their children showed increased
communicative attempts, vocabulary, listening, concentration and play creativity. Caregivers
reported that they saw improvement in their own effective communication with their children
regarding, providing communication opportunities, play, reading, parent child interaction and
that their relationship with their child improved as they became knowledgeable about their
child’s disabilities and impairments. Although not aimed at AAC in particular, this report
suggests the potential for caregiver-mediated communication intervention through a public
health avenue in South Africa.
In an attempt to improve services for caregivers, options such as caregiver education or
training have been recommended (Popich et al., 2007). It empowers the caregiver in such a way
that they feel they are no longer constantly dependent on the healthcare professional and that
they do not feel isolated anymore . They become empowered to problem solve and meet the
needs of their children . It is important to realize that professionals will continue to play a
consultative role with the trained caregivers (Popich et al., 2007).
For this reason, training caregivers to carry out interventions in low-income rural
contexts could be a solution to challenges related to access to services; and this form of
intervention would meet the basic needs of caregivers at a community level (Mandak, O’Neill, et
al., 2017; Hamblin & Koul, 2004). By the same token, caregiver involvement is important for the
success of interventions in contexts where the child lives, interacts, learns and plays (Granlund et
al., 2008). They also provide healthy, nurturing and stimulating environments for children (Child
Gauge, 2013) and most importantly they are the most essential communication partners for
young children (Ferm et al., 2011). Correspondingly, parents and/or caregivers are reported to be
their children’s first teachers (Kaiser & Hancock, 2004). Additionally, involving caregivers and
the family in interventions may be effective because they spend most of their time with the
children and interact with them in a variety of contexts, which will help with generalization of
skills. Caregivers are able to provide communication, participation and interaction opportunities
for the child (Granlund et al., 2008; Marshall & Goldbart, 2008). Interventions that occur
throughout the day of the child and within their families are reported to be less stressful and have
better results on communication development (Kashinath et al., 2006). When caregiver training
is provided in a systematic way, it has the possibility of alleviating the burden within the South

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 Chapter 2: Literature Review

African healthcare system in terms of rehabilitation for young children with DD and CCN. In
addition, teaching caregivers to implement AAC strategies within the child’s natural context
could increase the likelihood that such support will be maintained outside of therapy sessions,
which could result in positive communication outcomes for the children.
Vhavenda are an ethnic group of people residing predominantly in the Vhembe district of
the Limpopo Province in South Africa and they speak Tshivenda and its different geographical
dialects. They are descendants of various clans. The Vhavenda ethnic has a variety of cultures
stemming from Africa. Their economy is dependent on farming, manufacturing and mining.
People residing in Vhembe district are serviced by one regional hospital, six district hospitals,
one specialised psychiatric hospital, eight community health centers, 112 primary healthcare
clinics and 22 mobile clinics. Due to the district being predominantly rural, patients typically
have to travel distances of more than 5km by foot to access services either at a district hospital,
community healthcare centre, primary healthcare centre or mobile clinics that go into the deep
rural communities. There is a surge of undocumented and documented nationals from
neighbouring South African Development Community (SADC) countries such as Mozambique
and Zimbabwe who share the same strained public healthcare system in Vhembe.

2.8 Conceptual framework

The main aim of this study is to develop and evaluate the effectiveness of a caregiver
training programme designed to train Vhavenda caregivers of children aged 2-6 years with CCN
to implement AAC in a low-income rural context in South Africa. It is hypothesized that
caregiver training on various skills will improve the caregiver variables and the concomitant
child variables.
The study is grounded on the transactional model of development (Sameroff & Fiese,
2000), proposing that there is a bi-directional influence between the caregiver and the child that
shapes their communication interaction, which then influences communication development of
the child. It is also informed by Vygotsky’s sociocultural theory, which purports that
communication development is socially and culturally-mediated through interaction with more
knowledgeable partners. This theory also emphasises the need to create side tracks to speech for
a child living with CCN by enlisting the use of AAC for communication. Children living with

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 Chapter 2: Literature Review

CCN require competent adult models who will demonstrate and show them the use of AAC. This
brings to light the significance of training caregivers to model the use of AAC so that they can
fulfil their role as competent models for the child. The transactions between the child and
caregiver open up avenues of possibility for interventions to facilitate development of children.
In order to ensure that training is linguistically and culturally relevant, input from cultural
stakeholders will be sought prior to the development of the training programme. In this way, the
programme can be developed in line with the beliefs, values and cultural conventions around
caregiver-child interactions. Figure 2.1 illustrates how the caregiver training programme is
expected to change the interactions between caregivers and children with CCN. Frame A shows
that the caregiver initiations and responses (arrow from caregiver to child) fade over time, due to
minimal responses and initiations from the child (arrow from child to caregiver). This results in a
negative cycle that results in less and less interactions between caregiver and child. In Frame B,
the introduction of intervention strengthens the caregiver’s ability to respond contingently and to
initiate appropriately (arrow from caregiver to child) , in spite of limited child skills, Also, the
introduction of AAC offers the child more understandable means of responding and intiating
(arrow from child to cargiver). This results in a virtuous cycle where interactions increase over
time.

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 Chapter 2: Literature Review

Figure 2.1
Conceptual Framework

Caregiver scaffolds
communication through the
AAC use of culturally and
training linguistically appropriate
and methods that include the use
of AAC
resources

Child responds more as Access to

caregiver persists more. Child linguistically
communication is enhanced and culturally
by AAC use, leading in turn to appropriate
higher caregiver
responsiveness
AAC

Summary

30
 Chapter 2: Literature Review

This literature review commenced with an overview of language and communication

development, with specific emphasis on the theories that have attempted to explain the
phenomena. The role of the transactions between the child and the environment (and specifically
more knowledgeable partners such as caregivers) was discussed. The challenges that children
living with CCN encounter as a result of limited or lack of speech and language skills were
described, and the role that AAC can play in improving communication and language skills was
explained. The rationale for training communication partners and specifically caregivers in
supporting the use of AAC was also discussed, and background was provided as to why training
may focus on responsiveness, modelling and the creation of communication opportunities. The
potential application of caregiver training in the South African context was reviewed, and the
need to ensure cultural and linguistically appropriate intervention methods was explored. Lastly,
the conceptual framework underlying the study was briefly summarised and illustrated in Figure
2.1.

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 Chapter 4: Scoping Review

CHAPTER 3
METHODOLOGY
3.1 Introduction
This brief chapter provides an overview of the methods that were used in this study. The
chapter commences with the aims and sub-aims of the study. Thereafter, the paradigmatic
grounding of the study is explained, followed by a description of the study design. An overview
of the study phases is provided. Lastly, ethical clearance and the general ethical principles that
will be adhered to in this study are described in this chapter.

3.2 Aims of the study

3.2.1 Main aim of the study
The main aim of this study was to develop and evaluate the effectiveness of a
programme designed to train Vhavenda caregivers of children aged 2-6 years with CCN in a
low-income rural context in South Africa to implement AAC.

3.2.2 Sub-aims
In order to achieve the main aim of the study, the following sub-aims were formulated:
(i). To scope the literature on programmes aimed at training caregivers of young children
with CCN to implement AACs for the benefit of their children, in order to identify and
describe the participants in the training programmes, the training context, content,
instructional methods, materials, scheduling and delivery format, as well as the outcomes
and measures used to evaluate these. This information guided the development of the
CgTP (Phase 2);
(ii). To identify the cultural practices and beliefs of Vhavenda with regards to caregiver-child
communication interactions and children with communication disabilities, while also
eliciting stakeholder opinions about the proposed training. This information ensured
cultural congruity of the CgTP;

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 Chapter 4: Scoping Review

(iii). To develop a culturally- and contextually-appropriate CgTP designed to support

caregivers of children with CCN aged 2-6 years in Vhembe district, Venda, to implement
AAC;
(iv). To implement and evaluate the effectiveness of the CgTP designed to support caregivers
of children aged 2-6 years with CCN living in the Vhembe district, Venda, to implement
AAC.

3.3 Research paradigm

The paradigm informing the methodology of this study was pragmatism (Feilzer, 2010).
Pragmatists focus primarily on the utility of the study rather than on aiming to represent reality
or truth. Determining what is useful requires reflection on aspects such as the aim of the study,
the intended beneficiaries, and the researcher’s own values and the influence this has on the
study (Feilzer, 2010). This study aimed to develop and evaluate a programme designed to train
Vhavenda caregivers of children aged 2-6 years with CCN in a low-income rural context of
South Africa to implement AAC. The intended beneficiaries of the study were therefore the
caregivers and their children. The researcher herself is a Muvenda originally from Vhembe
district. She also trained as an SLP (Speech-language pathologist and Audiologist). She
embraces communication as a human right for all (CRPD, 2006) and believes in
communication being made available and optimal for all individuals. Although her background,
experience and values may have biased her towards interpreting the programme as effective,
she employed various methods in all phases to limit bias, such as joint coding and member
checking following stakeholder interviews and obtaining independent ratings of procedural
fidelity as well as reliability of the measurement in Phase 3.
Pragmatists accept that reality is a mixture of objective and subjective experiences, and
do not privilege one view of reality over another (Dewey, 1925; Rorty, 1999). For this reason,
pragmatic research typically consists of a combination of qualitative and quantitative
approaches, as both are deemed useful and, indeed, essential, to arrive at knowledge that is
relevant and useful (Feilzer, 2010). In line with this, the current study made use of a mixed
methods design.

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 Chapter 4: Scoping Review

3.4 Research design

This study employed a three-phase exploratory sequential mixed method design in order
to achieve the main aim. This implies that both qualitative and quantitative data were collected
and analysed to achieve the main aim of the study. This research design was chosen as data
collected in one phase informed the next phase (Creswell, 2014; Creswell & Plano Clark,
2018). Qualitative data was obtained from the exploratory phase (Phase 1), which informed the
development phase (Phase 2). The developed programme was then tested using a quantitative
design during the evaluation phase (Phase 3). Mixed methods allowed the researcher to collect
qualitative and quantitative data as appropriate for the specific phase of the project. Using
qualitative methods during the exploratory phase allowed the exploration of the topic from the
literature and from the stakeholders’ point of view. This phase was necessary as limited
knowledge was available about an appropriate and effective AAC training programme for
caregivers of children with CCN living in a rural South African Vhavenda community, and
qualitative methods offered the opportunity to explore findings from the literature and also
stakeholder beliefs and opinions in a flexible manner. The findings from this phase informed the
next phase, programme design, during which expert feedback was obtained through an open-
ended questionnaire (qualitative approach), and a pilot study (A-B design; quantitative
approach) was furthermore used to refine the training programme and procedures. Lastly,
during the evaluation phase, a SCED was used to evaluate the effects of the programme on five
variables that could be quantified through frequency counts. A quantitative experimental design
allowed the researchers to draw conclusions about the effectiveness of the training programme
to change the frequency of certain child and caregiver behaviours. A questionnaire with both
closed and open-ended questions (qualitative and quantitative) was used to evaluate the social
validity of the training programme. The use of primarily qualitative methods in the first two
phases enabled the researcher to develop a training programme that was informed by the
literature as well as by stakeholder input, strengthening the potential for the programme to be
both effective and socially valid. The primarily quantitative methods used it the third phase
allowed for an evaluation of the effectiveness and social validity of the programme.

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 Chapter 4: Scoping Review

The strength of the chosen design included, first of all, the judicious combination of
both qualitative and quantitative approaches, resulting in a more effective and socially-valid
training programme than would have been possible by using only qualitative or only
quantitative approaches. Secondly, the phases built logically onto each other, with a clear
progression from one phase to the next. Lastly, stakeholder voices were able to be included
prior to the programme design, during programme design, and also after the application of the
programme, thus strengthening the utility and social validity of the program (Feilzer, 2010).
Some challenges with conducting a sequential mixed methods study include the amount
of time it takes to conduct such a project with multiple phases (Creswell & Plano Clark, 2018).
Furthermore, the researcher needs to be competent in conducting, analysing and reporting data
using qualitative and quantitative methods (Schoonenboom & Johnson, 2017). In order to
ensure her own competence, the researcher attended trainings and workshops on qualitative
research methods and data analysis. The researcher also watched YouTube videos on mixed
methods that were presented by the authors in the field.

3.5 Phases of the study

The study employed a three-phase mixed methods exploratory design. Each phase
informed the following phase. Before commencement, approval for the whole study was
obtained from the Research Ethics Committee of the Faulty of Humanities (Appendix A), then
the Department of Health Limpopo (Appendix B1), District Health Vhembe (B2) and the
hospitals in Vhembe that offer Speech-language therapy services (B3). The methods, results and
discussion of each phase will be provided in more detail in Chapters 4 and 5 (Phase 1), Chapter
6 (Phase 2) as well as Chapters 7 and 8 (Phase 3). Figure 3.1. illustrates the overview of the
three phases and their aims.

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 Chapter 4: Scoping Review

Figure 3.1
Overview of the Phases

3.6 Summary
This chapter stipulated the aims of the study and explained the research paradigm that frames
the study. The design was then explained. Lastly, a brief overview was provided of the three
phases of this study, namely the exploratory phase with two data sources (a scoping review and
expert interviews), the development phase wherein the caregiver training programme was
developed, and lastly, the evaluation phase, whereby the caregiver training programme was
implemented, and its effects evaluated. CHAPTER 4
PHASE 1.1: SCOPING REVIEW OF CAREGIVER TRAINING PROGRAMMES
4.

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 Chapter 4: Scoping Review

4.1. Introduction
The scoping review was the first research conducted as part of the exploratory phase.
This chapter discusses the rationale for the review, the aims of the review, methods, results and
implications for the development phase.

4.2. Rationale
As discussed in Section 2.5, there is a strong theoretical and empirical basis for training
caregivers to scaffold the emerging communication skills of their children, including children
who require or use AAC. The current study proposed to develop and evaluate such a training
programme, and for this reason it was important to systematically search the literature to
identify existing programmes that could inform the development of the current programme. A
scoping review was therefore conducted to identify studies on AAC caregiver trainings and to
descriptively summarise various characteristics about the programmes and outcomes measured.
A scoping review, rather than a systematic review, was chosen because the aim was to identify
various characteristics of the programmes and the outcome measures, rather than summarising
overall effectiveness. A second reason for choosing a scoping review was that the researcher did
not want to limit the results to only experimentally-controlled studies. Doing so would have
resulted in excluding studies reporting on programmes that may as yet have only emerging
evidence of effectiveness, or studies that qualitatively described the implementation of such
training programmes. While systematic reviews and meta-analyses are helpful and necessary to
summarize the effectiveness of evidence (as determined by rigorous experimental
methodologies), the inclusion of other types of methodologies and designs in a review could
broaden the understanding of emerging interventions that have not yet been experimentally
verified. This may include studies that emanate from practice, as well as studies that attempt to
implement interventions in real-world and previously under-researched contexts. Because
interventions performed in real-world contexts are complex and transactional, they may lack
experimental rigor and control (internal validity) but conversely carry higher external or
ecological validity (Kent-Walsh & Binger, 2018).

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 Chapter 4: Scoping Review

4.3 Aims
4.3.1 Main aim
A scoping review was conducted to describe the nature of training programmes designed
for caregivers of young children with CCN in AAC interventions.

4.3.2 Sub-aims
In order to achieve the main aim, the following sub-aims were addressed:
(i) To describe the participants (caregivers and children);
(ii) To describe the training conducted (delivery format, content, and instructional
strategies);
(iii) To describe the outcomes targeted and measures used to evaluate the outcomes; and
(iv) To describe procedures used to enhance social validity of the programme before and
during implementation and measures used to assess social validity post training

4.4 Methods
The scoping review employed Arksey and O’Malley's (2005) framework. This
framework outlines the process as (a) identifying the research question, (b) searching for
relevant studies, (c) selecting studies, (d) charting the data, (e) collating, summarizing, and
reporting the results, and (f) consulting with stakeholders to inform or validate review findings.
The last step was addressed in a limited way in Phase 1.2 (see Chapter 5).

4.4.1 Protocol
A review protocol was developed at the beginning of the review, and was guided by the
PRISMA guidelines for scoping reviews (Tricco et al., 2016). This protocol specified the title of
the review, the rationale and specific research questions, the search strategy for the
identification of relevant studies, and the inclusion and exclusion criteria. The process for
screening was specified. The data extraction strategy was clarified and a data extraction table
was created. Various subject experts with a background in speech-language pathology and/or
AAC gave input on the protocol.

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 Chapter 4: Scoping Review

4.4.1 Search terms

Search terms pertained to the population of interest (parents of children who required
AAC) and the intervention of interest (parent training programmes that trained parents on AAC
implementation). No search terms specifying outcomes were added, as studies were not to be
selected on outcomes; any outcome was acceptable for inclusion. Information specialists were
consulted to assist with the refining of search terms, and pilot searches were then conducted.
The following search terms applied to this review and were tailored for each of the twelve
databases: parent OR caregiver AND child* OR youth OR adolescent AND complex
communication needs OR CCN OR little or no speech OR little or no functional speech OR
LNFS OR severe disabilit* OR developmental delays AND training OR education AND
augmentative and alternative communication OR AAC. The search strategy per database and
hits obtained from the search terms are summarised in Appendix C1.

4.4.2 Selection criteria

Studies were selected according to the following criteria outlined in Table 4.1.
Table 4.1
Inclusion and Exclusion Criteria for Studies
Criteria Inclusion Exclusion
Population • Caregivers or parents of children with • Studies where persons other than
CCN parents/caregivers are trained, e.g.,
• At least on child in the study had to have teachers, therapists
CCN (and results for this child-caregiver • Studies exclusively addressing
dyad had to be reported separately) training of children living with severe
• Children in the studies had to be aged sensory impairments (i.e. uncorrected
between 0-18 years. hearing and visual impairments; dual
sensory impairments, deafness,
blindness and etc.).
• Children over the age of 19 years
Intervention • Parent or caregiver is trained on any • Studies that train parents on skills
aspect of AAC/AAC implementation other than AAC implementation, such
with their child living with CCN. This as behavior management or
could include the implementation of any supporting their children’s speech
aided or unaided form of AAC. production
Outcome • Studies had to report on a primary • Studies that did not include a primary
empirical outcome related to the empirical outcome related to the
training. The nature of the outcome was training were excluded.
not limited and could include caregiver

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 Chapter 4: Scoping Review

Criteria Inclusion Exclusion

perceptions, caregiver behaviour, and/or
child behavior.
Date of publication • January 1998 to June 2019 • Studies before 1996 and studies after
June 2019.
Language • Studies published in English or with an • Non-English articles
English option if published in another
language.
Study/ research design • Empirical studies (i.e., studies collecting • Literature reviews of any nature
primary data from participants rather (systematic, scoping etc.) and theory
than reviewing other studies) using any papers were excluded.
design were included

Publication type • Include grey literature and peer reviewed • No studies will be excluded based on
articles the type of publication.

4.4.3 Data Sources

Twelve electronic databases were searched for peer-reviewed and grey literature. These
databases included: Academic Search Complete, Cumulative Index to Nursing and Allied
Health Literature (CINAHL), MEDLINE, PsycINFO, PsycARTICLES Scopus, ERIC, Family
and Society studies, Health Source: Nursing/Academic Edition, Africa wide, Humanities source
and Social, work abstracts. Each database search was limited by the date (January 1998 to June
2019) and language (studies had to be published in English). No limitations were placed on
study designs. Hand searches, as well as forward citations on Google ScholarTM, were
conducted. The researcher asked the following questions when selecting studies in forward
citations and hand searches: (a) Does it involve caregiver training? (b) Were AAC strategies
implemented by the caregiver? (c) Was the study published between 1998 and 2019? (d) Was it
published in English?

4.4.4 Study selection

Studies were exported from EBSCOhost via a Research Information Systems (RIS) link,
and the link was then uploaded onto Rayyan QCRI. Rayyan is a cloud-based web and mobile
application for systematic reviews that is designed for title, abstract and full text screening that
uses semi automation and allows collaboration between authors (Ouzzani et al., 2016). The
inclusion and exclusion criteria for this review (as provided in Table 4.1) were captured onto
Rayyan QCRI App and also onto a Microsoft Excel ® 2016 spreadsheet.

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 Chapter 4: Scoping Review

The aforementioned inclusion and exclusions criteria were used to select studies at title
level, abstract and full text level on Rayyan QCRI. Duplicates were removed after the RIS
downloads were uploaded on Rayyan QCRI. The researcher screened studies at title level and
selected studies for inclusion. The researcher and supervisors then screened the abstracts
independently. A consensus approach was used to resolve conflicts between the two reviewers.
This process was then also used to assess studies independently at full text level.

4.4.5 Data Extraction

Data extraction was carried out on a Microsoft™Excel 2019 document that was
designed according to the research sub-questions. The first version was designed by the
researcher. The researcher and supervisor then extracted data independently on the first 10
studies, and thereafter held a meeting to compare the extraction. Discrepancies were discussed
and resolved, and the data extraction table was jointly amended. Thereafter, the first and second
author independently extracted data from all 17 studies using the revised Excel document.
Descriptive information about each study was extracted (e.g., authors, year of publication,
design, and country in which the study was conducted). Further data extraction was guided by
the sub-questions. This included the population (e.g., number of caregiver participants, their age
and level of education, mean age of child[ren], diagnosis of the child[ren], children’s previous
exposure to AAC), followed by the intervention (i.e., delivery format, content, and instructional
strategies), outcomes (dependent variables and measures, results), as well as procedures to
enhance and also measure social validity. The data extracted by the two reviewers was
compared, and percentage of agreement was calculated. It amounted to 92.8%. Disagreements
were discussed and resolved by consensus. The assistance of the co-supervisor was enlisted on
one occasion when the first two reviewers did not manage to reach consensus.

4.5 Results
Figure 4.1 shows an outline of the study selection process as well as the number of
records at each stage of the process in accordance with the Preferred Reporting Items for

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 Chapter 4: Scoping Review

Systematic Review and Meta-Analyses (PRISMA) statement (Moher, Liberati, Tetzlaff, Altman
& The PRISMA Group, 2009).
Figure 4.1
Study Selection PRISMA (2009) Flowchart.

Records identified
=7939

7939 titles were eligible for title screening. 29 duplicates

Identification

were removed. Thus, 7910 titles were eligible for title

screening

Articles screened at title

level =7910
7779 titles were excluded at the title level, and 131 titles
Screening

were included for abstract level screening

Articles screened at
abstract level=131

98 articles were excluded, as they did not meet the

inclusion criteria. 33 abstracts were eligible for full-text
screening.

33 Full-texts articles
assessed for eligibility
Eligibility

Full-text records excluded, with reasons (N = 12)

No AAC implementation (N = 1)
Sensory impairments such as visual or hard of hearing or
deaf (N = 1)
Included

The study was not a caregiver training program (N = 1)

The study did not report on primary empirical data related
to the training outcomes (N = 8)
Date of publication was outside the criteria (N = 1)
21 Articles included in
scoping review

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 Chapter 4: Scoping Review

A total of 7939 titles were exported to Rayyan via an RIS link for title screening.
Twenty-nine duplicates were found and removed. A total of 7910 titles were screened and 7779
were excluded. Both reviewers then independently assessed the 131 abstracts with 97% inter-
rater agreement (agreements divided by the sum of agreements and disagreements). The
remaining 3% where disagreements existed were discussed and consensus was reached. A total
of 98 abstracts were excluded, because they did not report on primary empirical data related to
the training outcomes, focused on the wrong population as the paper did not report on parent
training or did not focus on AAC-strategies. Thirty-three studies were assessed independently
by both reviewers at full text level. Reviewers agreed on 96% (n = 32) and only disagreed on
one study. After consensus was reached by the reviewers, 21 studies were included for data
extraction at full text. A total of 12 studies were excluded. The reasons for exclusion were as
follows: the study did not address AAC implementation (n = 1); the study included only
children with hearing impairments (n = 1); the study did not report on a parent training
programme (n = 1); the study did report on primary empirical data related to the training
outcomes and /or detail contents of training (n = 8); and the date of publication was outside the
criteria (n = 1). A summary of the studies included is presented in Appendix C2.

4.5.1 Descriptive information

Of the 21 studies included, 12 were published in the time period 2010 to 2019 and the
other 9 studies between 2000 and 2009. The majority of the studies were conducted in the
United States of America (n = 14), while three were conducted in Sweden (Broberg et al., 2012;
Ferm et al., 2011; Jonsson et al., 2011), two in Kenya (Bunning, Gona, Newton, Hartley, et al.,
2014; Gona et al., 2013) and one each in Australia (Tait et al., 2004) and South Africa
(Bornman et al., 2001).
Study designs included quantitative experimental designs, namely quasi-experimental
designs (n = 4), randomized control trial (n = 2), as well as SCEDs (n = 6). Five mixed method
studies were found, including studies that employed a combination of focus groups and SCEDs
(n = 3); a combination of a survey with qualitative interviews (n = 1) and a combination of a

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 Chapter 4: Scoping Review

survey and a case study (n = 1). There were three studies that employed a case report and one
study that used a case series design.
4.5.2 Participants
4.5.2.1 Caregivers
Across the 21 studies, 380 caregivers were mentioned as having received training.
However, these may not have been unique individuals, since more than one study at times
reported on the same group of training participants (e.g., Romski et al., 2010; Romski et al.,
2011). Mothers were mentioned 267 times, and fathers (including one adoptive father) were
mentioned 80 times. One grandmother was mentioned. In the remaining studies, caregivers
were described as parents (n = 18) or as caregivers (n – 14). Caregiver age was reported on in
14 studies and ranged from 26 to 44 years (M = 36.2 years). In the 16 studies that specified
caregivers’ highest educational level, post-high school qualifications were reported 295 times,
and high school education 58 times.
In 14 studies, the caregivers’ home language was English and no mention was made of
other languages being spoken in the home. Three of the 21 studies reported on caregivers who
spoke primarily Swedish, with additional languages (i.e., Kurdish, Polish, Finnish, Tigrinya,
Russian, Arabic Turkish, Wolof, and Serbian) being spoken occasionally by some caregivers.
The three studies conducted on the African continent reported Afrikaans, Kiswahili, Giriyama,
and Conyi as the home languages. Rosa-Lugo et al. (2008) reported on caregivers who were
able to read Spanish and/or English; however, no detailed description was given of the specific
languages used in the study.

4.5.2.2 Children
There were 296 children mentioned in the studies. The mean age of the children was 56
months (i.e., 4 years, 8 months) with a range of 16 months to 12 years. They had a variety of
diagnoses, which included various neurodevelopmental disorders (ASD, CP, Down syndrome
and ID), other syndromes and genetic syndromes. Exposure to AAC before the caregiver
training was reported for 54 of the children and included prior exposure to the use of manual
signs, objects, Picture Communication Symbols (PCS), the Picture-Exchange Communication

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 Chapter 4: Scoping Review

System (PECS), photographs, and SGDs. No prior AAC exposure was reported for 18 of the
children and it was unknown for the remaining children reported on in the 21 studies.
4.5.3 Training
4.5.3.1 Delivery
The number of training sessions across the studies ranged from 2 to 24 sessions, with
one study not reporting the number of sessions. Frequency of training was not always clearly
described, but ranged from about twice per week to once per month. Not all studies reported on
total training time; however, from the studies that reported this, total time ranged from 75
minutes to 16 hours. Trainers consisted mainly of members of the research teams with the main
authors and research assistants acting as interventionists. A total of six studies reported on
results of group training strategy; however, three of these studies were based on one
programme (Broberg et al., 2012; Ferm et al., 2011; Jonsson et al., 2011) and the other two
studies (Romski et al., 2010; Romski et al., 2011) were based on another training. Group
training was conducted in central meeting places, laboratories and/or clinics, while individual
training happened in the homes of the participants. Homes were used for follow-up
measurements too. Face-to-face delivery was reported in most of the studies (n = 19). Other
formats included online delivery (n = 1) (Douglas et al., 2017), and self-study by parents
followed by support from the SLPs who regularly supported them and their children (n = 1)
(Calculator, 2016).

4.5.3.2 Content
Parents were trained to implement aided AAC, unaided AAC and, in some instances,
both (multi-modal AAC). Table 4.2 shows the frequencies of the AAC systems and the symbols
that were reported in the studies.

Table 4.2
AAC Systems and Symbols Used Across the Studies
AAC systems Description Number of reporting articles
Unaided signs Manual signs 5
Prelinguistic behaviours (e.g., natural 1
gestures, facial expressions)

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 Chapter 4: Scoping Review

AAC systems Description Number of reporting articles

Enhanced natural gestures 1
Aided symbols Objects 2
Photographs 3
Pictures and images (including clipart, 7
scanned images or images not otherwise
specified)
PCS 9
Minspeak 1
Dynasyms 1
Bliss 1
Widgit/Rebus 1
Graphic symbols (not otherwise 2
specified)
Aided systems/displays SDGs 13
Communication boards 8
Picture cards 5
Object displays 2
Placemat 1
PECS Book 1

The most common unaided AAC strategy employed was manual signs, while the most
frequently used aided AAC systems were SGDs. Aided symbols widely used on the displays for
the SGDs, communication boards, and picture cards were picture communication symbols.
Other systems included object displays.
Caregivers were taught to model augmented input strategies (i.e., caregiver augments
his/her speech with aided or unaided AAC symbols) in 15 of studies. In 11 studies caregivers
were taught to prompt the use of AAC (augmented output strategies). Caregivers were also
often taught to ensure that the child had an alternative method of expressing him-/herself (n =
15) through provision of communication opportunities. Other milieu teaching strategies (such
as asking questions, expectant delay, environmental arrangement, mands, contingent responding
etc.) were taught to caregivers in 20 studies. In three studies caregivers were additionally taught
to be responsive to their children (responsivity training).
Daily routines such as play (n = 6), snack time (n = 5), book reading (n = 6), leisure
activities (n = 4), educational activities (n = 1), caregiver led activities (n = 1), daily activities
(n = 5) and researcher chosen activities (n = 6) were used as settings in which caregivers
implemented the interventions.

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 Chapter 4: Scoping Review

4.5.3.3 Instructional strategies

The (Kent-Walsh and McNaughton (2005) instructional protocol was used in a few
studies in the review; however, it is evidence-based and includes fundamental elements for
training various communication partners. In the current review, caregivers were the
communication partners that the researcher focused on. The original protocol includes eight
steps; however, this study will use six of the eight steps:
(i) Pre-test and commitment to instructional programme - the researcher obtains formal
commitment to complete instruction.
(ii) Strategy description - the researcher describes the strategy, its components and steps
required to remember implementation of the strategy.
(iii) Strategy demonstration - the researcher models the use of the targeted strategy as well as
the components and skills needed to carry out the strategy.
(iv) Verbal practice of strategy steps – caregivers practice the strategy steps verbally. They
name and describe the steps of the strategy as outlined in the mnemonic.
(v) Controlled practice feedback - multiple opportunities for practice of targeted strategy in
a controlled environment are provided to the participants.
(vi) Advanced practice and feedback - the participants get to practice the strategies in a natural
environment, where the instructor gradually fades prompts.
(vii) Post-test and commitment to long-term strategy use - researchers document and review
the participants’ mastery of the strategy and compare the results to baseline.
(viii) Generalisation of targeted strategy – trainer supports the learning of how to generalize the
use of targeted strategy.
The four commonly-used instructional strategies included in more than half of the
studies included live strategy demonstration/modelling, strategy description, written materials
and guided practice sessions with the child, followed by feedback from the trainer as shown in
Table 4.3. Two strategies (self-reflection questionnaire and commitment to strategy) were each
only used once.

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 Chapter 4: Scoping Review

Table 4.3
Frequency of Instructional Strategies (in Descending Order of Frequency)
Instructional strategy Frequency Studies by numbera
Live strategy demonstrations or modelling 14 1-2, 6-7,9,11, 13-19,
21
Strategy descriptions 13 1,3-8,9-12,14, 17
Written materials 13 1, 3-5,8,10-12,14-
16,18,21
Guided practice sessions with own child, 13 1,6-8, 11-17,19,20
including feedback
Behavioural rehearsal or role-play with feedback 8 1,9,11-14,17
Homework 7 2-7, 18
Videotaping of caregiver-child interactions with 7 3-5,17,18,21,19
feedback
Video demonstrations of strategy 6 1, 10,11,14,17,18
Answering individual caregiver’s questions 5 10,12,14-16
Workbooks 4 3-5,8
Telephonic discussion 4 1,11,17,19
Verbal rehearsals 3 1,11,17
Lectures 3 3-5
Group discussions 3 3-5
Tests, quizzes and/or assignments with automated 2 8,10
or instructor feedback
Self-reflection questionnaires 1 10
Commitment to strategy statement/ questionnaire 1 10
a
Numbering as per Appendix C2

4.5.4 Outcomes
Of the studies reviewed, 15 reported outcomes related to both the caregiver and the
child, while five only reported on caregiver outcomes. One study only reported on child
outcomes.

4.5.4.1 Caregiver outcomes

Caregiver behaviour was evaluated in 13 studies. In these studies, caregiver behaviour
was observed, and then either qualitatively described (n = 1) or counted/classified (n = 12), the
latter typically according to study-specific definitions and parameters. In one instance,

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caregiver behaviour was measured according to the Responsive Augmentative and Alternative
Communication Style (RAACS) scale Version 2 (Broberg et al., 2012). In most studies, the
behaviour evaluated was directly linked to the behaviour trained, and entailed the use of
augmented input, output, and general milieu teaching strategies.
Caregiver perceptions and experiences as a primary outcome were measured in seven
studies. In three of these, their perceptions about the caregiver training programme
(effectiveness, acceptability, most and least valued aspects, etc.) were measured by means of
predominantly quantitative questionnaires and rating scales (Calculator, 2016; Ferm et al.,
2011; Starble et al., 2005). In one study, caregivers’ perceptions of the communication boards
introduced during training were specifically evaluated, using a questionnaire as well as by
means of interviews (Jonsson et al., 2011). The study by Gona et al., (2013) used qualitative
interviews to describe caregivers’ experiences of caring for a child with a severe
communication disability, and their experience of the caregiver training programme. Lastly, two
studies elicited caregiver perceptions about child communication skills (Bunning et al., 2014;
Calculator, 2016).

4.5.4.2 Child outcomes

Child outcomes were measured in a total of 17 studies. In 14 studies, all focused on
expressive communication skills, the outcomes were measured via observations/recordings of
behaviour. Three studies reported child outcomes based on caregiver rating. The 14 studies
making use of observations/recordings reported on expressive communication outcomes related
to pragmatics skills, morpho-syntactic skills, semantics, as well as combinations of two or three
of these outcomes. A total of 13 studies reported on pragmatic outcomes, such as frequency of
turn taking, or frequency of initiation, while four studies reported on semantic outcomes,
including the use of a unique vocabulary, the number of semantic concepts expressed, and
vocabulary gains; and three studies reported on morpho-syntactic outcomes, including the use
of multi-symbol messages, the correct use of pronouns, and the mean length of utterance.
Improvements in child communication behaviours were reported in all the studies. Furthermore,

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one study reported a decrease in challenging behaviours once the intervention had been
implemented (Olive et al., 2008).
Three studies reported on child outcomes through caregiver-completed rating scales.
The caregivers reported an increase in the child's competence in communication-related body
functions, body structures, and activities (Bunning et al., 2014). They also reported on increased
successful and unprompted use of enhanced natural gestures and decreases in challenging
behaviour (Calculator, 2016). Caregivers who had received AAC-related training perceived
their children’s communication as having become more successful, and they reported fewer
difficulties in their child’s communication compared to caregivers who had been trained merely
to support their child’s spoken communication (Romski et al., 2011).

4.5.5 Social validity: Caregiver input into programme and evaluation of social validity post-
training
In three studies, focus groups were used before the training programme was
implemented to ensure cultural appropriateness. In the studies by Binger et al. (2008) and Kent-
Walsh et al. (2010), focus groups were held with Latino culture experts, including one caregiver
per focus group. In the study by Rosa-Lugo and Kent-Walsh (2008), a focus group was held
with three African-American culture experts.
In eight studies, the authors reported that caregivers made choices about and/or gave
input on the training prior to its commencement. These included materials used (e.g., books),
the activities during which caregivers applied their newly acquired skills, the vocabulary, the
type of AAC, and the communication functions targeted. In two other studies, the content of the
training programme reported on was developed in consultation with caregivers from the target
culture to ensure cultural and social acceptability (Bunning, Gona, Newton, et al., 2014).
Apart from the seven studies that elicited caregiver perceptions about the training or the
change in their children’s communication skills post-training as (one of) the primary outcomes
(see Section 4.5.4.2), another six studies evaluated social validity post-training as an additional
secondary outcome. In all six studies, questionnaires were used with primarily closed-ended
questions (rating scales). In two of the studies, spouses of the participating caregivers watched

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and compared pre- and post-training videos of caregiver-child interactions, and blindly rated in
which videos the child communicated better (Binger et al., 2008; Kent-Walsh et al., 2010).

4.6 Implications for the development phase

The results of this scoping review had several implications for the development of the
caregiver training programme intended to train caregivers to implement AAC with their
children with CCN in their natural environments. The scoping review highlighted significant
elements of caregiver training approaches with regards to the participants, the training, and the
outcomes measured.
The scoping review strengthened the importance of evidence-based practice when
developing interventions by looking at the research evidence aspect of it. Caregiver input was
sought before and/or after the training in most of the studies. This highlights that consumer
perspectives in designing evidence-based interventions cannot be neglected when designing
programmes (Fulcher-Rood et al., 2020; Schlosser & Raghavendra, 2004). Instructional
strategies that were frequently used included: live demonstrations and modelling, descriptions
of strategies, inclusion of manuals or written materials, provision of practice sessions with
feedback, role-play or behavioural rehearsal, homework and video-taping of caregiver child
interactions. These strategies can be implemented and entrenched to adhere to principles of
adult learning. This will inform the strategies to be used by the researcher when training
caregivers to improve communication and interaction with their children. Data on the logistics
of training was extracted. This data informs the frequency of training, number of sessions and
how long the sessions should take. This will guide how the training session should be designed
with respect to the number of sessions and the length of the sessions. Data extracted on
demographic information of the caregiver and child will guide the researcher to develop
training content that will help caregivers of diverse educational levels and ages from different
contexts, as the studies were implemented in low and high income countries. Additionally, the
studies covered a wide range of diagnoses and ages of the children, so this means that the

51
 Chapter 4: Scoping Review

strategies and focus of the training can be utilized for various populations. Results pertaining to
the focus of training included the type of AAC systems and symbols used. Both aided and
unaided AAC was used; however, the use of picture communication symbols was reflected
significantly.

4.7 Summary
In this chapter, a scoping review was undertaken that aimed to describe the nature of
training programmes designed for caregivers of young children with CCN to implement AAC
interventions. The rationale for the review was described, followed by the aims and sub aims.
The method was described, including the protocol, search terms, data sources, study selection
process as well as the data extraction. The results pertaining to the population, the training, and
the outcomes were described. The implications for the development phase were given.

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 Chapter5: Cultural Stakeholders Interviews

CHAPTER 5
PHASE 1.2: CULTURAL STAKEHOLDERS INTERVIEWS
5.1. Introduction
The cultural stakeholder interviews were done to identify the cultural practices of
Vhavenda with regards to caregiver-child communication interaction, as well as their beliefs
about children with a communication disability; and to determine acceptability of the
proposed program strategies for the target population. The aim, sub-aims, participants, pilot
investigation and the outcomes thereof, materials and instruments used, data collection
procedures, data analysis procedures, findings, and implications for the development phase
are discussed.

5.2. Aim of Phase 1.2

5.2.1 Main aim of Phase 1.2
The aim of the interviews was to identify cultural practices and beliefs of Vhavenda
pertaining to caregiver-child communication and interaction with children with a
communication disability, and to obtain their opinions about various aspects of the proposed
training.

5.2.2 Sub-aims of Phase 1.2

In order to achieve the main aim, the following sub-aims were formulated:
(i) To determine the cultural conventions of typical caregiver-child communication
interactions, such as typical partners, activities during which communication is
common, and content of interaction, amongst others;
(ii) To determine the cultural beliefs of the Vhavenda about communication disorders, help-
seeking practices and interactions of caregivers with children with communication
disorders;
(iii) To determine acceptability of the proposed programme strategies and considerations for
a culturally-appropriate caregiver training programme to be developed in Phase 2.

5.3. Design
A qualitative phenomenological design was used to collect data. This approach was
used as it explores the perspectives of those who have experienced the phenomenon
(Neubauer et al., 2019). Thus, various cultural stakeholders were recruited to participate in

53
 Chapter5: Cultural Stakeholders Interviews

this study so as to explore their perspectives of the Vhavenda culture pertaining to cultural
practices and beliefs of Vhavenda concerning caregiver-child communication interaction,
children with a communication disability, and their opinions about various aspects of the
proposed training.

5.4. Participants
Approval for the whole study was obtained from the Research Ethics Committee of
the Faulty of Humanities, the Department of Health Limpopo, Vhenbe distric health and the
hospitals prior to the recruitment of participants. The approval letters can be found in
Appendices A and B.

5.4.1 Sampling
Non-probability purposive sampling with an additional element of snowball sampling
was used to select cultural stakeholders. The researcher purposefully chose participants
whom she knew to be knowledgeable on the subject of cultural and traditional practices of
Vhavenda, and/or who had experience in raising a child with a communication disability in
the Vhavenda cultural context. The researcher contacted two elders and two academics, as
well as three caregivers. She received additional referrals from these participants to other
participants.

5.4.2 Recruitment
The participants for this phase were recruited via phone calls and emails. Participants
who had no access to email addresses were phoned to find out if they would be interested in
participating in the research. Upon indication of interest, the participants were requested to
indicate their preferred communication platforms. The researcher sent the participants the
information letter in PDF format (Appendix D1) via WhatsApp™ and/or email containing the
link to the consent form (which was drawn up using Google forms see Appendix D3-D4).
The researcher kept a call logbook for phone calls.

5.4.3 Selection criteria

Participants had to meet a number of selection criteria, summarised in Table 5.1 with
justifications and measures that were used.

54
 Chapter5: Cultural Stakeholders Interviews

Table 5.1
Selection Criteria
Criterion and description Justification Measure
Participants should be 18 years They should be able to provide consent legally. Only adults were
or older. recruited.
Participants should speak The aim of the interviews was to gain Targeted recruitment
Tshivenda as their home understanding that enabled the researcher to ensured that only
language. develop a culturally-sensitive training Tshivenda speakers were
programme. The participants had to be from a recruited
Vhavenda cultural background. Home language
was used as a proxy measure.
They should currently reside or It was important that participants had knowledge This was verified during
originate from the Vhembe of the context in which the study was situated. the phone calls with
district. These could be individuals who originated from participants.
or were currently residing in Vhembe.
The hospitals from which the participants of the
evaluation phase study were recruited are
situated in the Vhembe district of Limpopo.
Participants should have access Interviews were conducted via the telephone. This was clear during
to a cellular phone and/or a Information (video clips and examples of recruitment as these
smartphone with access to communication boards) sent via WhatsAppTM or methods were used to
WhatsAppTM or Multimedia MMS so that the participants had context when recruit participants.
Messaging Service (MMS). the strategies that were envisioned for the
programme were explained.
Participants should be Participants from each of these groups were Targeted recruitment
knowledgeable about Vhavenda recruited as these persons were expected to be ensured that only persons
cultural traditions and customs. knowledgeable on the subject of Vhavenda belonging to these groups
Participants should therefore traditions and cultures, and/or had experience in were included in the
belong to one of the following raising a child with a communication disability in study.
groups: the Vhavenda cultural context. The reason for
• Elders with knowledge on including only caregivers of slightly older
tradition and culture of the children is that they likely had a greater wealth of
Vhavenda people; experience of raising a child with a
• Academics with communication disability, resulting in a wealth of
knowledge about tradition knowledge.
and culture of Vhavenda
people, employed at or
affiliated with an
institution of higher
learning in South Africa;
• Caregivers of a child with
CCN 8 years or older; who
has received or is still
receiving speech-language
therapy.

5.4.4 Descriptive criteria

A total of 11 participants consented to participating in the main interview; however,
only 10 were interviewed. One participant had network issues and could not engage in the
interview. Biographical data was collected at the beginning of the interview phone call.
Participants are described according to their age, gender, language, residence, smartphone

55
 Chapter5: Cultural Stakeholders Interviews

accessibility, interests or knowledge about culture and traditions, occupation and the group
they belong to (elders, academics or caregivers). Table 5.2 below shows the variables and
description. The cultural expertise of elders and academics is also described. The age,
diagnosis, and intervention history of the child with CCN (who is cared for by the caregiver)
is also described.

Table 5.2
Description of Participants (N = 10)
Participant Variables Graphic portrayal
Age
3
The ages of the participants ranged from 35 to 71

No. of participants
years, with a mean age of 51.4 years. Of the 10
2
participants, two were aged 50 years and 35 years
respectively. One each were 38 years old, 53 years
old, 55 years old , 62 years old, 65 years old with 1
the oldest one being 71 years old.
0

Age in years

Gender

Nine of the participants were female, and one was Male

a male. 10%

Femle
90%

Home language

All the participants spoke Tshivenda as a home

language. One additionally spoke English in the
home.

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 Chapter5: Cultural Stakeholders Interviews

Participant Variables Graphic portrayal

English &
Tshivenda
10%

Tshivenda
90%

Residence/origin

Six participants originated from Vhembe although

they no longer reside there. Four originated and
Reside in
resided in Vhembe.
Vhembe
40%
Originate
from
Vhembe
60%

Participant groups

There were four elders, three academics and three Academics

caregivers of older children with CCN. 30%
Elders
40%

Caregivers
30%

Occupation
4
Of the participants, three were self-employed, and
No. of participants

two each were educators, lecturers and retired. 3

One participant worked as a Dean of a University. 2
1
0

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 Chapter5: Cultural Stakeholders Interviews

The children of the caregiver stakeholder group ranged from 9 years to 16 years living
with CP, ID and other physical disabilities. Participants indicated that their interest in the
Vhavenda culture started during childhood. Six of the ten participants still practice some of
the traditions and four participants practice religious customs and Christianity. The majority
of the participants have a deep interest in the cultural attire, dances, practices of initiation
schools (for both males and females) and indigenous food.

5.5 Pilot investigations

Two pilot studies were conducted to test and determine the feasibility of the
procedures and methods to be employed (Thabane et al., 2010). Furthermore, pilot studies
were conducted to practice, assess the effectiveness of data collection and to detect problems
so as to change them before conducting the main study (Doody & Doody, 2015). Two pilot
interviews (one in English and another one in Tshivenda) were conducted in order to
determine the effectiveness of collecting interview data in both English and Tshivenda, as
well as ascertaining the feasibility of the interview schedules.

5.5.1 Pilot Investigation I

This pilot study was conducted with one participant. The participant was a 63-year-
old female who resides in Vhembe and is an educator. She obtained a PhD in African Studies.
She has a long-standing interest in the Vhavenda culture, in trying to understand the tradition
and culture. Her PhD study solidified the interest.
The researcher emailed the participant the information letter and sent the consent form
link via WhatsApp™. Once the participant consented to participating in the study, the
researcher phoned the participant to schedule the interview, as well as to ask which network
she used so as to send her data to view the videos and the communication board. The
participant requested that interview questions be sent to her in advance in order for her to
prepare for the interview. The researcher emailed the interview questions in both English and
Tshivenda so the participant could decide which language she would like to use during the
interview. The participant indicated that she would do the interview in English but would
include Tshivenda here and there. The interview took an hour and a half to complete.
Table 5.3 describes the aims, procedures, materials, outcomes and recommendations
of Pilot study I.

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 Chapter5: Cultural Stakeholders Interviews

Table 5.3
Pilot I: Aims, Materials, Procedures/Methods, Outcomes and Recommendations
Aim Materials Procedures/Methods Results Recommendations
To determine if the English information The participant was asked to read the The participant reported that Changes of the errors
information letter and letter (Appendix D1) letter and the online consent form and information was clear and
online consent form were Online consent form provide feedback to the researcher. understandable. The consent
clear for the participant. (Appendix D2) form had some errors due to
predictive text.

To determine the Cell phone The researcher phoned and then The participant provided The participants who might
feasibility of the Computer emailed the potential participant to consent via the online consent struggle with completing the
recruitment process. Information letter in introduce herself and the study to the form. The participant reported online consent will be advised to
PDF format participant. Preliminary interest in that she was initially not sure if ask someone at home to assist
Online consent forms participation was determined from the she would be able to complete them with completing it. The
phone call. The information letter in the consent form, but she did it researcher will orientate the
PDF format and a link to the online without help. participants to the online
consent was sent to the participant via consent form telephonically if
WhatsAppTM. The participant was they do not have someone to
asked to provide verbal feedback on assist them with completing it.
the ease of completing the consent
form online at the end of the
interview.

To determine if the Video clips from The videos were sent via At the end of the interview, the No changes will be made to how
participant could easily YouTube™ embedded WhatsAppTM to the participant to participant indicated that she the participants access the
access and relate to the onto PowerPoint (see view before the interview. The did not experience problems material. The participants will
materials sent (videos and Appendix D7) participant was expected to view the with accessing the material be asked to view the video
communication board). Communication board videos before the interview. The before the interview. She was before and during the interview.
(see Appendix D8) participant was asked after the able to access with ease and The videos can be played when
interviews if the materials were relate to the explanations given the researcher asks questions
accessible. by the researcher. 3.1-3.3 about the strategies.

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 Chapter5: Cultural Stakeholders Interviews

Aim Materials Procedures/Methods Results Recommendations

To determine feasibility of Cell phone Pre-interview phone calls were Biographical information of the Biographical questions will be
collecting biographical Biographical questions conducted by the researcher. The participant couldn’t be asked during the interview for
information before the participant was phoned so as to collected at the pre-interview all the participants.
interview. schedule interview time and also to phone call as the participant Sending of questions before the
collect biographical information from indicated that she was not interviews for the participant
the participant. feeling well. The biographical will be optional for all the
questions were deferred to the participants.
main interview.
To determine if the audio DW-Digital 8GB The researcher attached an external Both devices functioned No changes
recorder captured the Dictaphone and Voice microphone on the voice recorder and effectively.
interview effectively and Recorder then phoned the participant with her The uploading of the audio
whether the audio files Huawei T5 Nova cell phone on loudspeaker, placed next to recording was easy.
could be easily uploaded phone the microphone. Then researcher The recordings gathered were
from the recorder to the Laptop pressed record when the participant clear.
laptop. responded to the phone call. The
researcher uploaded the voice
recordings from the voice recorder
after every interview onto the
computer for analysis.
To determine the length of English interview The researcher checked the length of The English interview took an No changes
the English interview Schedule the recording at the end of the hour and 30 minutes.
Voice recorder interview.
To determine if the Recorded interview The researcher transcribed the The transcription and No changes
transcription verification Google drive interview and sent it to the research verification process was carried
process outlined by Clarke Transcribed interview assistant who listened to the recording out effectively. The research
et al. (2017) was effective. and checked the transcription against assistant understood his role in
the recording. The research assistant the verification process and
edited the transcription where errors what was expected of him. The
were noted and then sent the transcriptions were transcribed
transcription back to the researcher reliably and no errors were
who then went through it again. noted.
To determine feasibility of Transcription The data were coded according to the The researcher coded the No changes will be made to the
the thematic analysis in six Microsoft Word™ first three steps of the six steps as set transcripts and submitted the process
steps as proposed by Braun 2016 out in Braun and Clarke (2006, initial codes and themes to the
and Clarke (2006, 2013) Microsoft Excel™ 2013): becoming familiar with data supervisor. The supervisor then
2016 and transcribing data, generating commented and suggested

60
 Chapter5: Cultural Stakeholders Interviews

Aim Materials Procedures/Methods Results Recommendations

initial codes and searching for themes. shortening the codes. A
Thematic analysis was conducted to meeting was scheduled to
capture provisional codes and themes. discuss changes and
The researcher and supervisor had to discrepancies in the coding
verify the codes. The researcher and system, and the discrepancies
supervisor discussed the coding were resolved in that meeting.
scheme and a provisional coding A preliminary codebook was
scheme was developed from Pilot I then developed from the
and II. supervisor’s input and meeting.
To evaluate the interview Interview schedule The participant was interviewed using The participant struggled to The question about roles should
schedule by determining if the interview schedule (see Appendix understand the question about be removed.
the questions yielded data D5). The researcher read the roles and confused the ‘term The participants will be
that was aligned with the interview schedule as it was and caregiver’ with ‘domestic orientated to the term caregiver
aims of the interview asked questions as they appeared on worker’ (housekeeper). The before asking the questions.
the interview schedule. researcher had to rephrase and
probe a lot on this question.

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 Chapter5: Cultural Stakeholders Interviews

5.5.2 Pilot Investigation II

The researcher effected changes as recommended from Pilot Investigation I before
conducting the Pilot Investigation II. The first pilot interview was conducted in English; the
second pilot interview was conducted to test the comprehensibility of the Tshivenda interview
schedule, information letter and consent form script, and to evaluate the reliability of the
transcription and translation of the transcript from Tshivenda to English. A 53-year-old
participant who resides in Vhembe was interviewed for Pilot II. The participant was an elder
in her community and she is knowledgeable about the culture and traditions of Vhavenda.
She mentioned that she was taught by her elders about the culture and traditional practices, as
she showed interest in her early years. The participant has 35 years’ experience and interest in
the traditions and child rearing practices of Vhavenda. The participant obtained a secondary
school qualification (Matric), had adult basic education and training (ABET) in teaching,
administrative and clerical work and financial administration. She is employed as a financial
administrator. The results for Pilot II are depicted in Table 5.4.

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 Chapter 5: Cultural Stakeholders Interviews
Table 5.4
Pilot II Aims, Materials, Methods/Procedures, Outcomes and Recommendations
Aim Materials Procedures Results Recommendations
To determine if the Tshivenda The participant was asked to read the The participant reported that the No changes to content were
Tshivenda information information letter and letter and the online consent form information was clear and done, however, corrections were
letter and online consent Online consent form (Appendix D3 and D4) and provide understandable. The consent form done on the consent form for the
form were clear for the (Appendix D3 and feedback to the researcher. had some errors due to predictive predictive text errors reported
participant. D4) text. by the participant.

To determine the Interview schedule The researcher conducted the pilot The participant reported that the To use the word muundi or
comprehensiveness, clarity (Appendix D6) interview using the interview questions were comprehensive, clear mulondoti together when
and appropriateness of the schedule. The researcher noted and appropriate. conducting interviews in
interview schedule. questions on which the participant The participant recommended that Tshivenda.
required clarity. At the end of the the researcher use the word muundi
interview the participant was or mulondoti together to denote
requested to provide input on “caregiver”
questions that must be added or
deleted.

To determine the Recording of the The audio recording was transcribed Transcription and verification No changes
feasibility and length of interview verbatim in Tshivenda by the RA. The processes were conducted efficiently
the transcription and Transcribed transcription was verified against the and were completed in 12 hours
adapted back translation Tshivenda interview audio recording by the researcher. (transcription of the interviews took
process outlined by Lopez Translated interview The transcript was translated into 8 hours, the verification took 4
et al. (2008). transcription (English English by a bilingual Tshivenda- hours). The translator required a day;
version) English translator. The researcher he however did not specify how long
verified the translation against the it took him. The researcher spent 4
transcription. hours comparing the Tshivenda
transcription to the translation. There
were minor discrepancies found. The
researcher resolved them with the
translator telephonically.
To determine the length of Tshivenda interview The researcher checked the length of The Tshivenda interviews took an No changes
the Tshivenda interview. guide the recording at the end of the hour and a half (90 minutes)
interview.

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 Chapter 5: Cultural Stakeholders Interviews

5.6 Materials and instruments

Materials, equipment and instruments that were used to collect data for the interviews
will be discussed and described in this section.

5.6.1 Information letter and consent form

The information letters (Appendix D1 and D4) introduced the investigation and the
researcher. They outlined the title, rationale, procedures and ethical considerations of the
research. The information letter was compiled in English (Appendix D1) and was also translated
into Tshivenda by a lecturer in the department of Tshivenda at the University of Limpopo. The
Tshivenda letter was checked by the researcher as she is a bilingual Tshivenda – English speaker.
There were minor technical editorial errors that the researcher noted and corrected. The
Tshivenda translation (Appendix D4) had no grammatical errors. The English concepts were
depicted adequately.
An English electronic consent form (Appendix D2) was captured on Google™ forms, and
was translated into Tshivenda (Appendix D4) and checked in the same way as the information
letter. Both Tshivenda and English consent forms (Appendix D2 and D4) were then transferred to
an oline format using Google forms. The link was sent to the participants via WhatsAppTM so
that they could indicate whether or not they consented to participating in the research. Table 5.5
below shows the materials used and a brief description with the rationale.

5.6.2 Other equipment and materials

The other material and equipment used for Phase 1.2 are described in Table 5.5.

Table 5.5
Material and Equipment: Description and Rationale
Material Description and rationale
Interview schedule Description: The interview schedule was developed based on literature (see
(Appendix D5-D6) Table 5.6) and had three sections based on the sub-aims of the phase. Section 1
focused on communication interactions and had 11 questions. Section 2 was
concerned with cultural beliefs of Vhavenda towards communication disabilities
and it had four sub questions. Section 3 had questions related to the proposed
programme to be developed in Phase 2. These questions were related to the

64
 Chapter 5: Cultural Stakeholders Interviews

Material Description and rationale

proposed skills that the researcher would like to train caregivers on. There were
five sub questions in this section.
Aim: To identify and determine the cultural practices of Vhavenda with regards
to caregiver-child communication interaction and their beliefs about children with
a communication disability
Rationale: In order to develop a culturally sensitive, linguistically appropriate
and contextually relevant programme, interviewing participants who understand
the context would be the first step. This will aid in understanding the context
better.
Synthesized member Description: An email with an overview of what is expected of the participants to
checking (SMC) email do for SMC was sent out to them. This email also included a timeline of when the
(Appendix D9) participants should respond.
Aim: To provide the participants an opportunity to verify if the analyzed data
represents their views.
Rationale: As part of ascertaining trustworthiness, ensuring credibility of data is
important in qualitative research
Summary of data Description: A written document with a summary of the results was sent out to
(Appendix D10) the participants via email (see Appendix D10). There was also an audio file
version of the summary that was compiled by the researcher. the researcher read
and recorded the written summary in short clips according to the themes for the
participants. This allowed participants to access the information in a format of
their choice (written or audio).
Aim: To provide the participants an opportunity to listen to or read the results of
the interviews so as to verify or add more information.
Rationale: As part of ascertaining trustworthiness, ensuring credibility of data is
important in qualitative research
Material to demonstrate Description: Materials included a 36-sec video that depicted the proposed skills
AAC-related that were sourced from YouTube™
communication skills that (www.youtube.com/watch?v=l2eDYGCR2NQ) and a communication board
the researcher intended to created by the researcher using picture communication symbols from Boardmaker
train (Appendix D7-8) online (mealtime activity board). The mealtime activity board had 12 items on a
3x4 grid, using the modified Fitzgerald key for colour coding grammatical
categories and parts of speech. The research used brown shaded symbols for
people. Furthermore, mealtime vocabulary that is typically used by caregivers for
and children was chosen and used on the boards.
Aim: Materials were developed so that the participants of the interview would
understand the concepts of augmented language input, creating communication
opportunities and responsiveness.
Rationale: With AAC being still relatively unknown in the Vhembe district, it
was important that the researcher gave the participants a visual referent for the
skills explained to them.
Voice recorder with Description: A DW-Digital 8GB Dictaphone and Voice Recorder with an
external microphone external microphone attached to it was used so as to record the interview directly
from the phone while it was on speaker.
Aim and rationale: To record the interviews so as to allow for verbatim
transcription thereafter.
Cell phone Description: Huawei Nova T5 cell phone was used to phone the participants and
conduct the interviews.
Aim: To phone the participants.

WhatsAppTM Description: It is an instant messaging and Voice Over the Internet Protocol
application that is used to text, call and send media in various formats.
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 Chapter 5: Cultural Stakeholders Interviews

Material Description and rationale

Aim and rationale: To send videos, letters and the communication boards to the
participants.
GoogleTM Drive Description: It is a file storage and sharing service offered by Google™.
Aim and rationale: To share documents and different files (audio files) with the
Research Assistant for analysis.
Laptop Description: A laptop was used to email and share resources with the
participants, upload the interviews from the recorder, and analyse the data using
ATLAS.ti
Aim: To store and analyse data.
ATLAS.ti 8 Description: It is a computer assisted qualitative data analysis software
(CAQDAS) that was used to conduct thematic analysis according to Braun and
Clarke’s (2013) steps and procedures by Nowell et.al. (2017).

5.6.3. Development of the interview schedule

The interview schedule was developed based on the literature on early communication
intervention and cultural diversity. The cultural adaptation process model (Baumann et al., 2015;
Bernal et al., 2009; Domenech Rodriguez et al., 2011) , ecological validity model (Bernal et al.,
1995) and ecocultural theory (Weisner, 2002) informed the development of the interview
questions. Table 5.6 describes the development of the interview schedule. It depicts the aim,
question, theoretical justification and the implications for programme development.

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 Chapter 5: Cultural Stakeholders Interviews

Table 5.6

Interview Schedule Development

Sub-aim Interview Questions Theoretical How this could

justification potentially influence the
program
1. To determine cultural
conventions of typical
caregiver-child
communication interactions
1.1. To determine who In a typical Vhavenda family, who would be likely to communicate Many communication To determine if
children typically or speak with a child aged 6 years or younger? intervention programmes caregivers are primary
communicate and interact Who would communicate the most to the child? target caregiver-child communication partners
with or who is likely to dyads. However, in most of the child in the
interact with children African cultures children Vhavenda culture as the
aged 6 years or younger. grow up in ‘extended intended programme
families” in which they aims to train caregivers
might have multiple of children with CCN.
partners (Geiger &
Alant, 2005). The child
therefore does not only
interact with the mother
or primary caregiver in
the course of the day
(Louw & Avenant,
2002). However, the
literature also
emphasizes that the
caregiver is an important
communication partner
and are capable of
creating communication
opportunities for their
children (Granlund et al.,
2008; Kaiser & Roberts,

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 Chapter 5: Cultural Stakeholders Interviews

Sub-aim Interview Questions Theoretical How this could

justification potentially influence the
program
2013; Marshall &
Goldbart, 2008;
Pennington et al., 2004)
It is thus important to
understand if this is the
case in the Vhavenda
culture.
1.2. To determine what What activities do caregivers and children aged 6 or younger usually Activity settings are Knowing which
activities caregivers and engage in during the day? During which activity settings do adults important in how communication-rich
children typically engage and children typically talk? children develop caregiver-child activities
in during the day; and During which ones would it possibly be inappropriate or unusual to communication within are typically conducted
which ones are rich in talk? What may be the reasons? the family context will enable to researcher
communication (Balton et al., 2019; to incorporate these into
opportunities. Bruder, 2010). They the intervention
provide an environment programme.
in which the child learns
communication and
other skills. Furthermore,
they are important to
take into consideration
as they give insight to
what is important for a
particular culture and
what is valued in order
provide for validity of
interventions. It will also
provide an understanding
of what is considered
important in influencing
the family and the child
(Bernheimer et al., 1990;
Skinner & Weisner,
2007; Weisner, 2002).
Interventions focused on

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 Chapter 5: Cultural Stakeholders Interviews

Sub-aim Interview Questions Theoretical How this could

justification potentially influence the
program
caregiver-child
interactions should be
based on daily activity
settings in order to make
use of the already
existing authentic
learning experiences
within the natural
context.
1.3. To determine the purpose For what purpose would caregivers interact or communicate with a Cultural conventions The aim of the
of communication child aged 6 or younger? What is the importance of speaking to the differ from one culture to programme is to infuse
interactions between child? another with regards to AAC into caregiver-child
caregivers and children What is the purpose of young children speaking to caregivers? Is it the communication interactions in a
seen as important for the child to do so? functions that are culturally relevant and
appropriate in caregiver- congruent manner. As far
child interactions. Geiger as possible, typical
and Alant (2005), communication functions
describe caregiver child in adult-child interactions
interactions in a should be maintained in
traditional Botswana the intervention. For
context, and note that example, when
children typically did not caregivers are taught to
ask caregivers questions. create communication
Asians parents do not opportunities, they
express emotions openly should be taught to do so
during parent-child in a culturally relevant
interactions or on a daily manner.
basis (Awde, 2009; Vigil
& Hwa-Froelich, 2004).
So it is important that
purposes of
communication
interaction understood
within Vhavenda culture.

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 Chapter 5: Cultural Stakeholders Interviews

Sub-aim Interview Questions Theoretical How this could

justification potentially influence the
program
Which will in turn
influence the activities
and vocabulary of the
purpose.
1.4. To determine particular When caregivers and children interact during …. (name activity that Culture influences It is important that these
pragmatic aspects of respondent described as communication rich), how would this pragmatics skills social conventions are
typical caregiver-child usually happen? For example, where would the child be positioned (Turkstra et al., 2017). It highlighted so as to avoid
interactions. (This in relation to the caregiver? Would the child make eye contact? is important that these cultural bias in the
question is optional and What kind of things would the caregiver say, and what kind of social conventions are current programme.
will only be used if things would the child say? Who would initiate verbal interaction highlighted so as to Some of the pragmatic
additional clarity is and who would respond? avoid cultural bias (van skills are westernized and
needed.) Kleeck, 1994). During might not be applicable
parent-child interactions, to Vhavenda culture. It is
children learn more than important that the
just words, thus, programme includes
understanding social pragmatics skills that are
conventions or congruent to the
pragmatics skills is vital Vhavenda culture during
in intervention planning parent child
for young children with interventions.
language and
communication
difficulties. In some
African cultures, eye
contact is prohibited and
seen as a sign of
disrespect, however this
rule might not be
applicable in younger
children but in older
children (Murovhi et al.,
2018). It is important to
see which pragmatics
conventions are

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Sub-aim Interview Questions Theoretical How this could

justification potentially influence the
program
prohibited and not
include them in the
program.
2. To determine the What cultural or traditional beliefs do Vhavenda hold regarding It is important for help Understanding cultural
Vhavenda cultural beliefs communication disability in children? (What are their perceptions of givers or professionals to beliefs about
about communication communication disabilities?) understand the cultural communication disability
disorders, forms of beliefs of the clients and intervention will
communication and Would a caregiver of a child with a communication disability about a particular assist the researcher to
interventions for usually seek help or intervention for their child? What would be the condition in order to identify what role a
communication disorders expectation of the intervention? provide culturally parent training
sensitive and responsive programme as one
interventions (Bernal et intervention option can
al.,1999; Bernal et al., be expected to play.
2009; Louw & Avenant, Knowledge of beliefs
2002) will influence how the
programme introduces
theoretical or conceptual
models of improving
communication
interaction between
caregivers and their
children.
What other forms of communication (besides speech) are accepted? It is of utmost value to It is important to
Please provide examples of these methods and what messages may understand the modes of understand how the
be communicated with these methods. communication which communication modes
are accepted in the are applied in interaction
Vhavenda culture in the Vhavenda culture,
because they help what this modes are used
communicate a variety for and which ones are
of communication culturally acceptable.
functions. They are also This will influence how
important in the programme will
understanding how incorporate different
communication modes. This will further

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Sub-aim Interview Questions Theoretical How this could

justification potentially influence the
program
interaction between a inform coding of
caregiver and a child interaction during testing
occurs (Mcfadd & of the programme in
Hustad, 2020; Lindsay Phase 3.
Pennington &
McConachie, 1999).
Communication is
multimodal and should
be treated as such even
when introducing AAC.
There are benefits to
multimodal
communication and that
of AAC (Alant et al.,
2006; Lundälv et al.,
2014; Romski & Sevcik,
1997; Schlosser &
Raghavendra, 2004;
Sennott et al., 2016;
Sigafoos & Drasgow,
2001)
You have already told me how caregivers and young children Caregivers are reported It will inform the
without disabilities typically interact. In what way may these aspects to dominate parent child activities that the
be different if a child has a severe communication disability? interactions with researcher will use for
(prompt on partners, activities, purposes, roles) comments and question. the training which are
This shows an reported to be rich.
asymmetry in Furthermore,
interactions between understanding the
caregivers of typically dynamics of interaction
developing and that of will inform choice of
children with disabilities theory or model that will
(Anderson et al., 2015; form the development of
Jennifer Kent-Walsh & the programme. This
McNaughton, 2005; will moreover inform

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 Chapter 5: Cultural Stakeholders Interviews

Sub-aim Interview Questions Theoretical How this could

justification potentially influence the
program
Light et al., 1985; what to include in the
Midtlin et al., 2015). training material and
resources.

3. To determine For my research project, I am planning to train caregivers on three According to the It is important to ensure
acceptability of some of specific aspects. ecological validity model mechanisms of change
the program content and Responsiveness: This means a caregiver expects a child to (Bernal, Bonilla & are compatible with the
methods communicate and reacts to the child’s behaviour as if the child is Bellido, 1995), cultural patterns of the
communicating or speaking. So, for example, if the child points to intervention is likely to clients, in order to ensure
something the caregiver will give it to the child, as if the child asked be effective if it is accessibility and
for it. Responsiveness also means that the caregiver pays attention compatible with the acceptability of the
to what the child is looking at or doing, and comments on it. The cultural patterns of the program.
caregiver may also imitate that the child is doing (Broberg et al., participants. An
2012; Shire et al., 2016; Yoder & Warren, 1998). ecologically valid
intervention is culturally
In the video I sent you, you could see that the child focused their sensitive .
attention on the doll’s tummy. The adult recognizes that and
responds by saying tummy. The child then lifts the doll and pats it -
the adult responds by saying /hug- big hug/ while patting her own
doll. The child points to the side with the cot and the adult responds
by turning to the cot and taking out a doll. She reacts to the pointing
as if the child asked something.
Would teaching parents to act in this way be culturally appropriate
in your opinion? If not, could it be changed to make it more so? Is
there anything I should be aware of during this process to make sure
it is acceptable to caregivers?

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Sub-aim Interview Questions Theoretical How this could

justification potentially influence the
program
Providing communication opportunities: the caregiver can
encourage the child to communicate by asking a question, letting the
child choose between things or by arranging the environment in
such a way that the child is tempted to ask for something. The latter
include strategies such as offering the child small quantities (e.g.,
biscuit, bite sizes of fruit and etc.) and withholding more until the
child asks, placing desired items out of reach but in sight (e.g.,
desired food in a see-through tightly closed container), and creative
stupidity. Once the opportunity has been offered, the caregiver then
waits for 3-5 seconds for the child to respond, and then they can
fulfil the child’s response to the choice they made. If the child does
not respond, the caregiver can attempt to cue a response by helping
the child reach for they want or like. (Douglas et al., 2013; Muttiah,
2016).
Offering small portions: In the second video, I sent you, the adult
gives the child a chocolate. The adult then closes and hides the
chocolate packet. The child comes closer to the adult and the adult
waits for a communicative attempt. The child the says /chokie
please/, the adult gives the child another piece of chocolate.
In the third video, the adult shows the child a banana and an apple
and asks the child which one she wants. The child grabs the apple
and vocalizes /aah/

Would such a strategy be culturally appropriate in your opinion? If

not, could it be changed to make it more so? Is there anything I
should be aware of during this process to make sure it is acceptable
to caregivers?

Modelling augmented language input:

Parents will be given picture boards like the one I sent you. I will
teach them to point to pictures as they are talking to the child. In this
way they can teach the child to also point to pictures (Dada & Alant,
2009; Drager et al., 2006; Harris & Reichle, 2004).

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 Chapter 5: Cultural Stakeholders Interviews

Sub-aim Interview Questions Theoretical How this could

justification potentially influence the
program
In the video: On this video you can see an adult talking and pointing
to the relevant pictures on a picture board. For example, the adult
said “today we worked” and she pointed to the picture of work.
When she said “we were all done with work, we go to play with
toys” and she pointed to all done, go, play and toys on the picture
board.
In the same way, the mealtime board can be used by both the
caregiver and the child. The caregiver might signal the end of the
mealtime activity by telling the child the tummy is full. The child
can show “more” when they want more food. The adult can request
the child to open the mouth by saying and pointing to picture
showing ‘open mouth’

Would such a strategy be culturally appropriate in your opinion? If

not, could it be changed to make it more so? Is there anything I
should be aware of during this process to make sure it is acceptable
to caregivers?
Would it be acceptable for me as a speech therapist to train
caregivers of young children with communication disabilities to
communicate more effectively with their children? What aspects
should I be aware of in order to ensure that the training will be
respectful and acceptable to caregivers?

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5.7 Data collection procedures

These interviews were conducted telephonically due to the Covid-19 pandemic and the
interview material was sent via WhatsApp™ and shared through Google™ Drive. Interviews
were conducted using a regular cellular telephone call. Interviews enable a researcher to obtain
information from the participants’ point of view (Dilshad & Latif, 2013). Telephone interviews
have certain advantages. These include cost-effectiveness, as time and money for travelling to an
interview venue are not required for the researcher and the participants (Vogl, 2013) and they can
be done with participants regardless of their geographical setting (Irvine, 2011). There have been
reports of reduced social pressure and researcher bias associated with conducting telephone
interviews (Farooq & De Villiers, 2017). Furthermore, this was the best way of collecting
interview data, considering the Covid-19-related lockdown restrictions.
The telephone interview process as outlined by Farooq and De Villiers (2017) was
followed; however, adaptations were made to this protocol for this research. The step-by-step
guide included: pre-interview phone calls, setting up the interview, and conducting the interview
as well as ending the interview appropriately.
Pre-interview calls: The researcher phoned the participants (after they consented to
participate) in order to schedule the interview. Participants were asked which network they used
so as to send them 1GB data for viewing videos and the communication board sent to them. They
were also asked what platforms to use to send them materials.
Negotiating interview environment and setting when preparing interview: The audio
recorder and cell phone were prepared accordingly and tested during pre-interview calls to
ensure that the sound quality was good and communication was intelligible between interviewer
and interviewee. The recording equipment was tested to ensure recordings were audible and
intelligible.
Main interview: The researcher followed the interview schedule (see Appendix D5-6) to
conduct the interviews. The researcher introduced the research, and reiterated the participants’
rights to withdraw at any time or refrain from answering a question. When asking the interview
questions, the researcher used the interview guide flexibly. In response to participants’ answers,
the researcher summarised, rephrased and checked for understanding, and also probed further as

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the need arose. The researcher communicated presence (e.g., saying, “yes,” “uh-hah,” “mmm”)
so that the participants would not feel as if they were talking to themselves during the interview.
Ending the interview: When interviews ended, the researcher asked the cultural
stakeholders if there was anything else they wanted to add to the responses they had given. They
were thanked and assured that they could contact the researcher if they needed further
information. Furthermore, they were reminded that analysed interview data would be sent to
them to ensure that the analysis expressed their views (synthesized member checking [SMC],
Birt et al., 2016). The researcher saved the recordings and backed them up.

5.8 Data analysis

Before the thematic analysis process, interviews were transcribed and prepared for
analysis. Thematic analysis was done to analyse qualitative data collected from the cultural
stakeholders' interviews.

5.8.1 Transcription
Transcriptions of English and Tshivenda interviews were done by the researcher and
research assistant on Microsoft Word 2016™. The researcher and research assistant split the
interviews evenly amongst themselves. The transcriptions and audio recordings that were
conducted by the researcher were sent to the research assistant for first pass verification of the
transcription (Clark et al., 2017). The research assistant is bilingual in English and Tshivenda. He
was a 3rd year Bachelor of Education student at the University of South Africa (UNISA). The
research assistant listened to the audio recordings against the transcription to make sure that they
were accurate and complete. Where errors were found, they would be corrected and noted by
typing them in a different colour or highlighting where the mistake was. The verified
transcription was sent back to the researcher who checked it against the recording to check the
content for final verification (second pass verification). This process was replicated for the
transcriptions carried out by the research assistant and checked by the researcher. These
processes have been recommended to ensure reliability transcriptions (Clark et al., 2017).
English transcripts were uploaded onto the ATLAS.ti 8 for analysis.

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5.8.2 Translation of the transcripts

The audio recording was transcribed verbatim in Tshivenda by the research assistant or
the researcher. The Tshivenda transcription was verified against the audio recording by the
researcher if transcribed by the research assistant and vice versa if transcribed by the researcher.
The verified transcription of Tshivenda interviews was translated from Tshivenda to English by a
bilingual Tshivenda-English expert. The expert is a lecturer in the School of Language and
Communication studies and holds a Master’s degree in African Languages – Linguistics and
Literature. The researcher verified the translated transcription as she is a bilingual Tshivenda-
English speaker. The researcher verified the translated English transcript against the Tshivenda
transcript. The English version of the Tshivenda transcriptions was uploaded onto the ATLAS. ti
8 for analysis.

5.8.3 Coding
Thematic analysis was done to analyse the interviews from the cultural stakeholders
(Clarke & Braun, 2013; Nowell et al., 2017). This was done using a CAQDAS, namely
ATLAS.ti 8. The six steps, according to Clarke and Braun (2013), were applied in the coding
process and are represented in Table 5.7.

Table 5.7
Thematic Analysis Process (Braun & Clarke, 2013)
Phases How thematic analysis was done in this research
Phase 1 Verbatim transcriptions of the raw interview data were done by the researcher
Becoming familiar and others by the research assistant. In this way she became familiar with the
with data and data. The researcher read and re-read the transcribed interviews, and wrote down
transcribing data impressions and thoughts about the data.
Phase 2 Initial codes were assigned to meaningful segments of the transcription. The
Generating initial codes were assigned with regards to the interview questions and aims. The
codes supervisor verified coding of the first two transcripts from the pilot. A code list
was then developed. (Round 1a). The researcher independently coded the first 3
transcripts from the main interview. The supervisor checked the coding once
again, and the amended list of codes formed the basis of the coding scheme for
the other transcripts.
Phase 3 Codes were then refined to ensure that each code is unique (Round 2 coding).
Searching for Codes were grouped under themes/categories and subthemes. Theme generation
themes was done according to the research question. The coding scheme was further
developed to reflect themes, subthemes and codes.

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Phases How thematic analysis was done in this research

Phase 4 Round 3 of coding: The themes, subthemes and codes in the provisional coding
Reviewing themes scheme were reviewed by the researcher and the supervisor according to the
coded data and the whole data set. All text segments coded using a specific code,
subtheme and theme were grouped to enable easy checking of consistency in the
coding. Changes were made as necessary. The supervisor checked the coded
data. Any proposed changes were discussed with the researcher and consensus
was reached.
Round 4 coding: This round of coding involved further merging of codes and
categorizing them according to the sub-themes. The Atlas ti. folder was sent to
the supervisor for final comments and discussions.
Phase 5 The researcher and the supervisor defined and named the themes, where
Defining and disagreements arose, they had a consensus meeting to resolve definition of
naming themes themes. This was done on Atlas.ti. 8. The researcher would define themes and
send the folder to the supervisor for checking. In the meetings held via Zoom, the
researcher and supervisor would discuss and agree on themes and definitions.
Phase 6 Summaries of the themes and subthemes were written up and supported by
Producing the illustrative quotes from the data. Themes were interpreted in the light of the
final report research questions and previous literature and theory.

Coding of the results on ATLAS.ti 8 was done over four rounds in order to categorise and
summarise data by the researcher and the supervisor. Furthermore, the process was done to
ensure that the coding process was reliable.
Round 1a: the researcher conducted open coding independently using phrases to tag the
data segments from the pilots. The coding process allowed the researcher to condense or reduce
the data (Saldana, 2016). An inductive approach was employed. The supervisor checked and
made suggestions to the codes as well as compressing the codes. From this attempt, a first draft
codebook was developed and used to code the first three main interviews. A total of 285 codes
were generated from the two pilot interviews.
Round 1b: the researcher independently coded the data from the first 3 main interviews
using the codebook developed form the pilot interviews and 623 codes were generated from this
coding process. The researcher and the supervisor met to resolve and clarify some of the codes. A
consensus was reached for the code differences. A revised codebook was developed.
Round 2: The last 7 transcripts were coded using the revised codebook from round 1b.
The researcher coded independently. The supervisor checked the codes and reduced and merged
some. The 623 codes were reduced to 246. At a consensus meeting, the need to further reduce
codes was discussed.

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Round 3: Some codes were merged according to the discussions at the consensus meeting
held in Round 2. The codes were further reduced from 246 to 205 in this round.
Round 4: This round of coding involved further merging of codes and categorizing them
according to the sub-themes. The researcher and the supervisor agreed on developing a table with
theme, sub-theme and examples.

5.9 Trustworthiness of data

Credibility, confirmability, reflexivity and transferability were aspects of trustworthiness
that were considered in this research.
Credibility: Credibility refers to the confidence that can be placed in the truth of research
findings (Anney, 2014; Gunawan, 2015; Nowell et al., 2017). This entails whether or not the
findings represent credible information drawn from the participants’ original data and if it is the
correct interpretation of the views they expressed during data collection. The researcher
conducted synthesized member checking of the interviews with participants to ensure their views
were well-represented (Anney, 2014; Leedy & Ormorod, 2016; Maguire & Delahunt, 2017;
Nowell et al., 2017).
Synthesized member checking was done with the interview participants. An email with
instructions (Appendix D9) together with a written and/or audio-recorded summary (see
Appendix D10 for the written summary) of the results were sent to the participants. The
participants were requested to go through the summary to verify if the results represent their
views. If not, they were requested to highlight what needed to be added and what needed to be
removed. Only one participant made additions to the summary pertaining to allowing the
caregivers to take the lead and the researcher being a guide during training. PA03 added that,
when this is done, caregivers take ownership of the training and “it does wonders”. The rest of
the participants felt their views were well-represented. However, AC01 commented on a typo in
the document.
The researcher and her supervisor coded the data over four rounds to ensure that the
coding process was reliable. They also held consensus meetings in order to resolve
disagreements and discuss codes and possible themes.

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Transferability, Confirmability and Reflexivity: Transferability is the extent to which

results can be transferred to other contexts with other participants. The researcher wrote the
research process so as to ensure that other researchers would be able to replicate the research in
different contexts.
Confirmability and reflexivity are the degree to which the research can be corroborated
by other researchers and ensuring that the data and interpretation are the views of the participants
and not the researcher’s imagination. The researcher kept a reflexive journal that detailed what
happened during data collection to ensure reflexivity and confirmability (Anney, 2014; Noble &
Smith, 2015; Nowell et al., 2017). A script was followed to carry out the interviews. This ensured
consistency in the interview process. Thus, procedural fidelity was maintained by adhering to the
interview script. During data analysis, two coders coded the data to enhance confirmability.
The data obtained from the interviews can be deemed trustworthy because of the
processes followed in transcription verifications and also the translation and verification done for
the data as outlined in Sections 5.6.1. and 5.6.2 above.

5.10 Ethical considerations

Ethics comprise of principles that underlie morality that can be applied to research
(Leedy & Ormrod, 2014; McMillan & Schumacher, 2014). The following principles, as set out in
the Belmont report Appendix Volume II (1979), guided this study:
Informed consent: The participants were provided with information about the study in a
language (Tshivenda or English) in which they are comfortable prior to the data collection by
means of an information letter. This letter also included a link to the consent form. Participants
were also encouraged to seek further clarification from the researcher on any aspect of the
investigation from the researcher or her supervisors if needed. All 11 participants who were
contacted consented to participate in the research by agreeing on the Google™ Forms link. This
was done independently, although some participants noted that they were supported by a family
member to help them access Google forms.
Voluntary participation: The participants were reminded in the consent letter that they
were entitled to voluntarily participate in this study and that they were allowed to withdraw from
the study at any given time, without negative consequences, or punishment of any sort. They
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were assured that non-participation would not disadvantage them in any way. If participants
should choose to withdraw, their data would not be used. Participants were once again reminded
of these rights at the beginning of the telephonic interview. However, no participant withdrew.
Protection from harm and respect for participants: This study did not involve any
invasive procedures and there were no risks of physical harm associated with participation.
However, some unintended form of harm could have been caused as information shared in the
interview might arouse sensitive emotions from the caregivers such as having to share their
perceptions and experiences with communicating with their children with CCN and disabilities; a
process which may be difficult and may bring the limitations their child faces to the forefront.
The researcher made provisions to ensure that there was a certified and registered counsellor on
stand-by to debrief the participants in case any emotional issues arose during data collection. She
also ensured that participants were not subjected to embarrassment or any loss of self-esteem and
treated all the participants with respect. Finally, the researcher also ensured that the questions
asked did not, in any way, subject the participants to any form of discrimination and/or prejudice.
The right to privacy and honesty: The confidentiality of the participants was maintained
in this study as they were allocated identification numbers as a form of protecting their identity.
Their names were thus not written on any of the forms; however, the researcher created a
separate file that was password-protected with a register and the names of the participants. The
file was stored in a different folder from the one with the rest of the information pertaining to this
research.

5.11 Findings
Thematic analysis was guided by the interview questions. Three themes could be
identified from the data that were closely related to the questions posed. These themes were (a)
typical interactions for young children; (b) communication disability; and (c) comments on the
proposed training (appropriateness and acceptability, as well as suggestions for change). A forth
theme emerged from the data. This theme was less closely linked to a specific question but was
nevertheless reflected in the comments of various participants. This theme was concerned with
changes over time. The four themes are described in more detail in the sections below and quotes
are provided to exemplify the themes. Quotes are provided in italics, with additions by the
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researcher in parentheses. Repetitions, vocalizations, or false starts were omitted for ease of
reading, and these omissions are indicated by ellipsis points (…). Care was taken that the
meaning of the original utterance was not changed by the omissions. Where participants
switched to Tshivenda, the English translation is provided in braces {}. The codes assigned to
participants indicate to which group they belonged, that is, caregivers (PA01-PA03), elders
(EL01-EL04), or academics (AC01-AC03).

5.11.1 Theme 1: Typical interactions of young children

The theme ‘Typical interactions of young children’ encompassed any comments
describing the interactions of young children with others, and specifically with caregivers. Six
subthemes were identified under this theme, relating to (1) interaction partners, (2) the activities
that young children typically engage in, (3) the purpose of communication, (4) how they interact,
(5) topics that they talk about and the communication functions they express, and (6) other
accepted forms of communication. Participants provided detailed descriptions of the interactions
of young Vhavenda children without disabilities aged 6 years or younger. It became clear that
children engage in a variety of activities with various partners, and that communication occurs
during many of these activities, for various purposes. Table 5.8 shows the sub-themes, categories
and examples of codes assigned as well as frequency with which this code appeared in the
composite transcript.
Table 5.8
Theme 1: Typical Interactions of Young Children
Sub-theme Category Examples of codes Frequency
Interaction Family members Mother 8
partners Grandmother 6
Parents 4
Other (siblings, female elder, grandparents, 1
helper)
Father 3
Other Peers 8
Activities Communication rich Where communication takes place 38
No communication Meals 13
When adults are talking 2
Play Caregiver led 3
Child led 13
Importance of Child-to-caregiver 9
communication Caregiver-to-child 12
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Sub-theme Category Examples of codes Frequency

Purpose and Purpose: Child-to- Sense of agency 1
importance of caregiver Talk about plans for the future 1
communication For safety purposes 1
Speech and language development 4
Social closeness 3
Purpose: Caregiver- Inability results in reduced self -efficacy and self- 1
to-child esteem
Social closeness 1
Language and communication skills 13
Self esteem 2
Link between parent-child interactions and 4
relationship
How interaction Pragmatics and set up Eye contact 10
occurs Adult-initiation of communication interaction 8
Child-initiation of communication interaction 5
Proxemics and positioning 7
Topics and Child-to-caregiver Communication functions 10
functions Child focused topics 2
Caregiver-to-child Communication functions 17
Taboos 1
Other forms of Unaided Various, such as gestures and sign language;
communication communication facial expressions; miming and mouthing words; 18
pointing to objects; demonstrations
Touch 6
Aided communication Pictures and drawings 2

5.11.1.1 Interaction partners

Mothers are partners that were frequently mentioned by the participants. Other partners
include grandmothers, grandparents, both parents, siblings, elderly female people and other
children. Some specific remarks in this regard included:
It would be the mother or the female elders. (AC03)
Yah, uhm you know… the mother… uhm if the mother is not working, uhm, grandmother,
if the grandmother if the grandmother is alive. (AC01)
In a sense that she (mother) is the one who carried him/her for 9 months (…) and after
birth that child would be spending his/her time with the mother, the mother will be the
one taking care of her making sure she is clean, she has eaten, breastfed, mmm so, while
she will be doing that even if the child is still in the age of not being able to respond to…
to the mother verbally (…), the mother will be doing all those things talking to the child.
(EL02)

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5.11.1.2 Activities
Activities that young Vhavenda children engage in with the interaction partners were
categorised into activities that fostered communication, those that were not considered suitable
for communication, and play. The participants reported that activities which stimulated
communication included child routines, caregiver-led activities (i.e. household chores),
educational activities (i.e. drawing, painting), entertainment activities (i.e. watching TV) and
physical activities (running, jumping). The household chores included the activities that the
caregivers do around the house such as making the bed and sweeping. The participants
mentioned how children try to imitate their caregivers. Educational activities included caregivers
reading stories to their children and drawing.
Children engaged in play with their caregivers and other children. However, child-to-
child play was mentioned frequently. It involves children playing with peers as opposed to
adults. Some play activities were described to be adult-led such as playing cards with the
children.
…the setup for play in typical Venda context is that the child would be expected to play
with others (other children). (AC01)
In the Vhavenda culture, there are times when communication is prohibited. One does not
eat and talk; and children are also not allowed to talk when elders are talking. These were
activities that were categorised under no communication.
Especially during eating time, they’re being taught that we’re now starting to eat, nobody
must talk. (EL03)

5.11.1.3 Purpose and importance of communication

When participants were asked about the importance of communication between the
caregiver and the child, they unanimously agreed that it was important. Caregivers discussed
both the importance of caregiver-to-child and child-to-caregiver communication.
To further explore the importance of communication, participants were asked about their
perceptions about the purpose of communication. Caregivers reported that they communicate
with their children for pedagogical reasons and for nurturing. Pedagogical reasons included
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teaching them morals, values, respect and how to communicate. Caregivers also play a vital role
in nurturing and modelling how children experience positive emotions towards others. Therefore,
they communicate to foster the relationship between them and the child, for it to be a safe one
and for the child not be scared of them. For example:
…the child gets to know right from wrong because of the conversations. You … cannot
just come and blame a child that what you did it was wrong and have you had a chance
to explain or to have that communication in between the two of you so that why I find it
as important to communicate as early as it can be. (PA03)
It is very important yet again as the mother can start teaching the child right from wrong
and also the mother can start teaching the child manners so that the child will not grow
up lacking manners and being disrespectful. The mother will also help their child to not
be too rough whilst playing with other kids. (AC02)
It is very important, as it makes it very easy for the child to then be able to communicate
with their parent or guardian freely and without any fear. (EL04)
Also, to enhance the language and communication skills of the child, as well as self-
esteem seemed important. The most frequently-mentioned purpose as to why caregivers need to
communicate with their children was in order to increase their speech-and-language repertoire.
Yes, it is important for parents to constantly talk to the children especially for those that
live in provinces such as Gauteng whereby so many different languages are spoken. So
parents must constantly talk to their young children in their home language or mother
tongue so that they may be able to learn how to speak their own language without any
issues. (AC02)
The participants showed that children communicate with their caregivers to ask
questions, to express the sense of agency and to talk about their plans for the future. Child safety
is an important aspect for caregivers, and one function of the child’s communication would be to
alert caregivers if any abuse was encountered.
and also see what agency they (children) hold to effect change around them. (AC01)
He (child) like to tell me like mama when I grow up, I will buy you so many cars when I
grow up, I want to be like this. (PA01)

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Children also communicate in order to increase their speech-and-language repertoire.

This was evident in the following statement:
It is important that children are encouraged to speak back, uhm you know… so that they
can experiment with words and sound. (AC01)
It was reported that when children are unable to communicate, it becomes difficult for
them to express who they are, which results in a reduced sense of self-efficacy and self-esteem as
described in this extract
…if the child is not able to express themselves in ways that they can be heard it will begin
to affect their sense of self, self-efficacy and self-esteem. (AC01)

5.11.1.4 How interaction occurs

Participants were asked about how interactions happen during certain activities that they
had mentioned earlier in the interview. In response to this question, pragmatics and the set-up of
the interaction were described. Pragmatic conventions that the participants indicated included
eye-contact and who usually initiates the interaction between the caregiver and the child.
Maintaining eye contact was a convention generally used by caregivers during interaction for
various reasons.
Yes there will be eye contact. (AC02)
Furthermore, the caregivers were reported to be the ones who initiated communication
with their children frequently. They initiate interaction to establish the basic needs of the children
and also to stimulate communication development in certain instances. Caregivers will also
initiate in instances where the child is passive or shy.
…it’s usually the parent that starts talking. (AC03)
But some children are very shy and very quiet in a way that the mother should start.
(EL03)
Children also have the opportunity to initiate interaction with their caregivers in some
instances and this is guided by what they would like to get across to the caregiver or when the
child wants to express a basic need. Almost half of the participants described it.
But it usually depends on who wants something from the other. For example, if the child
is hungry, they will tell the parent… (AC03)
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Participants were also asked about the physical set up for interaction between the
caregiver and the child. They reported on how far or close the child and caregiver will be from
each other. However, how close or far the child is from the caregiver or vice versa depends on
the activity they are participating in at that moment. This can be demonstrated by the following
quotations:
…like maybe lying on the side of the parent. (EL01)
It depends on what is happening at the particular time, for example whilst eating the
child can be sitting next to the parent, or leaning against the parent, if bathing or the
parent can just be nearby whilst the child is playing. (AC03)

5.11.1.5 Topics and functions

Caregivers and children talk about different topics and their communication fulfils a
number of functions. The communication functions expressed by caregivers and children overlap
in some instances and in other instances, they are different. Caregivers express a variety of
communication functions in their interactions with their children. These functions include
commenting, answering questions, giving their child instructions and directives, explaining
requests and/or directives, asking the children questions, as well as teaching them.
and if the child needs assistance to eat… you know... whatever that involves to be saying
ndi khou toda u {I want to.. } dzhiani hafha {take this}, ni do fhedza nah? {will you
finish?}. Ndi ni engedzedze nah? {should I give you more?} No fura naa? {are you full},
all that and uhm yah. During bath time to be talking about you know, anything that also
just… the possibility of the child to begin to wash parts of their bodies themselves.
(AC01)
On the other hand, the communication functions of children include expressing their
needs/wants, sharing emotions, transferring information to their caregivers, asking questions,
commenting about events and topics that are child-focussed. Children also communicate to make
requests and talk about events.
It is the time that those children are asking so many questions…because they want to
know the questions like what? How? Why? Can you see? Why this happen? What is this?
Why is this? (EL01)
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I think they should… be able to communicate with their parents so that we can know
how… they're feeling and to be able to express anything, what is happening in their life
and what they enjoy, what they love actually. (PA02)
Regarding topics, there are some topics that are considered taboo in the Vhavenda
culture, which cannot be discussed with the child. A stakeholder who is also a caregiver indicated
that topics around sex are prohibited and are taboo.
In our Venda culture, you can’t you can't talk about sex. (PA02)

5.11.1.6 Other forms of communication

Caregivers in the Vhavenda culture use nonverbal forms of communication to interact
with their young children. Non-verbal communication involves aided forms which entail the use
of aids that are external to the body such as pictures or objects. Unaided forms of communication
include using gestures, sign language and facial expressions. These communication means can be
used for different reasons and serve different functions.
Aided forms of communication that participants reported included the use of pictures that
are readily available or pictures that caregivers can draw in order to communicate with their
children. The unaided forms included the use of gestures, sign language, facial expressions,
miming and mouthing words, pointing to objects and demonstrations. With the unaided forms,
participants mentioned a specific look that they use to communicate with children, gestures, and
sign language. This is illustrated by the following quotations:
…or just look at them in a way that lets the child know that what they are doing is wrong.
(AC03)
…they can even talk by actions, like, like actions or miming, like maybe there are visitors
or maybe the child is free coming there shouting, the caregiver can put the finger on the
mouth saying keep quiet or miming, mmm he or she can understand them. (EL01)
…if the child did something good, the parent can clap for the child without actually using
the words. (AC02)
Some of the aided forms of communication used by caregivers included the use of
pictures as shown by the two quotations below:

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You can also maybe you use pictures, if you do not have pictures you can just take a pen
or a pencil and a paper and then you draw something… (PA03)
You know, for a child to understand what you're, you’re saying to them. I think the best
way is when you're showing them the picture, they more relate to picture kind of thing.
(PA02)

5.11.2 Theme 2: Communication disabilities

This theme is concerned with the perceptions of Vhavenda regarding communication
disabilities, beliefs about the cause, help seeking practices, expectations of help seeking, types of
help, interaction partners, differences in communication with typically-developing counterparts
and the activities they engage in with their caregivers. Table 5.9 describes sub-themes, categories
and examples of codes that were identified in the data. Three categories were identified under
this theme, relating to: (1) beliefs about the cause; (2) help seeking; (3) interactions; and (4)
expectations.
Table 5.9
Theme 2: Communication Disabilities
Sub-theme Category Examples of codes Frequency
Beliefs about the Supernatural Witchcraft 9
cause of Curse or taboos (Parents are being 6
communication judged)
disabilities Caused by other people 3
Will of the ancestors 1
Witchcraft not seen as cause 1
Genetic Hereditary 2
Traditional Use of Muthi (traditional medicine) 2
Help seeking Help seeking practices Cultural practices 5
Outcome of help seeking 4
Parents do not seek help 2
Parents do seek help 1
Expectations of help Positive change 12
seeking practices Parent benefits 1
Social support 1
Type of help Attend training 2
Educational/schooling 2
Healthcare 12
Religious 6
Social assistance/grant 2
Traditional healer 6

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Sub-theme Category Examples of codes Frequency

Miscellaneous (Other) 2
Reasons for/influences Availability of services 2
on help seeking Awareness, knowledge, information and 9
practices education
Caregiver beliefs 8
Caregiver emotions 3
Caregiver practices 3
Interactions Partners Family members 10
Differences No differences 1
Differences 2
Communication Nonverbal means 11
Partner communication strategies 3
Lack or limited 4
Raising a child with Pragmatics 1
(communication) Awareness 1
disabilities Acceptance 8
Stigma 3
Caregiver emotions 2
Caregiver patience 3

5.11.2.1 Beliefs about the cause of communication disability

When participants were asked about Vhavenda’s perceptions of the causes of
communication disability, witchcraft was most frequently mentioned as the perceived cause.
Curses or taboos were other causes of disability believed by Vhavenda according to the
participants. Communication disabilities are believed to be caused by other people as a form of
revenge, evil or envy towards the family of the child with disabilities.
…unfortunately the belief(s) around witchcraft …are… there. (AC01)
…it was very difficult because, they used to believe that if somebody is being born
disabled, it will, it means, he/she is being witched before being born. (EL03)
Hereditary factors were also believed to cause communication disability. However, it
seems like Vhavenda tend to believe the child would have inherited the disability from the
mother’s side of the family.
For example, when a child has a communication disability, the Vhavenda people usually
start to look at the mother’s side of the family as a way of suggesting that the child may
have inherited the disability from the mother’s side. (EL04)

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It was also mentioned that caregivers tend to be judged for having a child with a
disability. For example, they may be accused of having contributed to the cause of the disability
because they used traditional medicine ‘muthi’.
and others will say we ‘fara-fara’{fara-fara- is a word used in Tshivenda for using
traditional medicine translated as touch-touch}, that’s why her child is like this or that.
(PA01)

5.11.2.2 Help seeking

The participants reported that some of the caregivers seek help, while others do not seek
help for different reasons. However, it is noteworthy that not all help-seeking endeavours were
assumed to be successful. Those that seek help do this in order to determine the source of the
problem. When caregivers do seek help and are satisfied with the kind of help they receive, they
will pass the information on to other parents. For the caregivers who do not seek help, this would
be due to practices such as hiding the child or because of their beliefs.
For example, one participant said:
Yes we do seek help but, we do seek help ‘cause, we seek help just because we want to
know like what is the problem of the child when my child is talking like this…. (PA01)
Usually people with children with communication disabilities often hide the children at
home as they feel like the children are a curse to them. (AC02)
…normally we do not. They will stay with the child and the child will grow and become
an adult without even getting any help. (PA02)
When participants were asked about caregivers’ expectations when seeking help, they
indicated that everyone expects a positive result from their endeavours regardless of the help
sought, whether it is spiritual, medical or traditional. However, depending on the type of help
sought, expectations may be different. When parents consult pastors or traditional healers, the
expectation may be complete recovery and disappearance of any disability. On the other hand,
caregivers who consult medical practitioners may expect improvements in their child’s
functioning, without necessarily expecting a complete healing. Another expectation is that the
child would start talking. Apart from help-seeking expectations, there are expectations that are
held by other participants regarding a child with a communication disability. Children with
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communication disabilities are expected to learn how to talk when using nonverbal/ alternative
methods.
My own expectations were that, I wanna see a change from my son’s life…Ok! I
understood … from the doctors that is condition is permanent. But, now with the
explanation that was given was that if you attend this and this and that there are
possibilities that he might move from position one to position two. Even though it’s not a
fully complete healing…(PA03)
I, if especially these who is going through the religious route and the traditional route.
They expect miracle. They expect that if I can take my child out there, the pastor will pray
to my child then he/she will be okay. And also the one who’s going through the traditional
route, they are expecting the traditional healer to heal the child and be like other people.
(EL03)
There was also an expectation that the child would eventually talk. Participants perceived
that caregivers expect health professionals in general to help them with strategies to
communicate with their children with communication difficulties, and to assist them in order to
get a social relief grant.
Their expectation is to… think that the - maybe the child will get help so that he can…
she can… he/she can speak. (EL01)
…they usually just come to talk to the social worker to ask for the grant for the child.
(AC02)
Regarding the type of help, caregivers reported that they sought spiritual, medical,
educational and social assistance for their children with communication disabilities. Participants
reported that some caregivers would seek help from traditional healers, while some sought help
from healthcare practitioners such as doctors, speech language therapists and physiotherapists.
Seeking help from healthcare practitioners may be motivated by attempting to receive social
assistance in the form of disability grants for the children, as a completed evaluation by a
healthcare practitioner, with a formal medical diagnosis, is a prerequisite for the grant. Another
source of help for caregivers includes readily available materials on the internet and learning
resources that can assist them. An elder highlighted that since the world is changing and people
are increasingly educated, they are in a position to get help from different sources.
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Nowadays, parents usually take their children to doctors and speech and hearing
therapists as soon as they realize that their children have a communication disability,
whereas the people in the olden days would usually go to the traditional healers in order
to seek for help for the child from the traditional healers. (EL04)
Awareness of services or lack of thereof influences help seeking behaviour. Caregivers of
children with communication disabilities were reported to, at times, be unaware of the services
available to them and their children until they consult a doctor, typically due to medical
emergencies. Doctors or nurses then make them aware of the child’s communication problem
and the services available from other healthcare practitioners. If caregivers are aware of services,
and have information about the services, they are more inclined to make use of these services.
Beliefs of caregivers also tend to influence how they go about seeking help for their child
with a communication disability. Parents with certain faith convictions will take their children to
pastors and prophets for prayer and await a miracle. Moreover, if they feel the child was meant to
have a disability, they do not seek any help. Most parents will seek help out of feelings of
frustration and also in a quest to determine what is wrong with the child. The caregivers’
indigenous cultural/traditional practices will also influence their help seeking. Practices such as
hiding the child will prevent caregivers from seeking help.
So as they stick to their own believe they tend to sit down and relax and they do nothing
while is still early. (PA03)
…you will sometimes find parents seeking services that will reflect this belief they think
that witchcraft somewhere or punishment you know… so you will have people wanting
the child to be prayed over. (AC01)

5.11.2.3 Interaction
Regarding interactions with children with communication difficulties, participants
highlighted that frequent interaction partners for children with communication disabilities are
their mothers and other family members who play the motherly role in families without mothers.
Unlike for children without disabilities, peers were not mentioned.
…the family members in the house where they are living of which the mother is always
the first priority I do not know why but its…like that. (PA03)
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When participants were asked about how interactions occur for a child with a
communication disability, they reported that during interaction, participants noted that there were
breakdowns in communication that occurred due the nature of the communication disorder. This
also highlighted the differences which exist in communication between typically-developing
children and children with communication disabilities. These differences include repetition,
speaking slowly and being patient with the child. Also, children with communication disabilities
have limited exposure to interaction due to caregivers speaking less to them, using fewer words
and the children not being included in interactions like their typically-developing peers.
for a child who is unable to speak, it’s difficult right? How will we communicate because
the child will do what they want and I will not do what the child wants because I cannot
hear (understand) her. So it’s difficult. (PA01)
…its trial and error for a while and often times you know, parents and adults would use
words less than they would typically use when the child has a communication disorder…
(AC01)
The interaction will be different because you will be talking to the child and the child
won’t be answering you… (EL02)
The participants further identified non-verbal means including vocalizations, use of sign
language, drawing pictures and use of eye contact.
It will be important for one to draw something for a child with a communication
disability so that the child can be able to choose what he or she wants …For example the
parent can draw the pot and show it to the child, and if the child wants to go to the toilet,
they can just point at the pot drawing to let the parent know. (AC02)
…this child who cannot speak, I think parents will just, they will demonstrate using
concrete objects maybe in the morning when they’re giving them food to eat. (EL01)

5.11.2.4 Raising a child with a communication disability

Emotions that caregivers experience when raising a child living with a communication
disability cannot be discounted. Caregivers tend to experience difficulties because they find
themselves isolated, as reported by one of the parents: "…because I know how difficult it is to

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have a child with a disability." Moreover, "sometimes you do not have someone to talk with and
laugh with like it’s difficult, very difficult.” (PA01)
Despite the difficulties associated with raising a child with a communication disability,
parents reported that one needs to exercise patience when communicating with their child as
indicated by two of the parents. For example:
It requires that you have a big heart in a day. Even on days that we do what the child
does, it’s like the child gets used to doing the activity but it requires patience. And having
a child with a disability also requires patience. (PA01)
With that I think and I still believe each child deserves a chance. I should not always be
in a hurry to say child please respond quickly, because this is me, (I) am an adult I know
how to communicate and I know when (I) am communicating with an adult I get quick
response. So with a child it’s gonna be a different issue and it’s gonna take time for a
child to respond back. So I think whenever you are speaking with a child you should do it
and know that you do have time for that. (PA03)

5.11.3 Theme 3: Acceptability, appropriateness and suggestions for the proposed training
The theme encapsulates the participants’ perspectives on the appropriateness and
acceptability of the proposed strategies and materials that caregivers would be trained to
implement with their children with CCN during the last phase of the study. It also encompasses
suggestions that the participants made for changes or improvements to make the training more
appropriate and acceptable for Vhavenda caregivers. Four sub-themes were identified which are:
(1) skill, (2) training, (3) materials, and (4) other. Table 5.10 below shows the subthemes,
categories, code examples and frequencies.

Table 5.10
Theme 3: Acceptability, Appropriateness and Suggestions for the Proposed Training
Subtheme Category Examples of codes Frequency
Skills Responsiveness Appropriate 11
Inappropriate 2
Considerations 4

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Subtheme Category Examples of codes Frequency

Suggestions 3
Creating communication opportunities Appropriate 9
Inappropriate 2
Modelling aided language input Appropriate 11
Training Suggestions Promoting acceptance 17
How to train caregivers 24
What to train (content) 5
Other Trainer Characteristics 6
Material Appropriate 1
Inappropriate 1
Suggestions 6
Other Cultural sensitivity 4
Activity example 2

5.11.3.1 Caregiver skills proposed for training

The participants were asked to comment on responsiveness, creating communication
opportunities, and modelling aided language input. A total of 11 comments suggested that the
participants perceived responsiveness as appropriate and acceptable. Participants provided
examples and also commented on the videos that depicted the skill.
I think this responsiveness communication is good. It’s good. (PA02)
So for me the two things that I picked up from the video one is: you matter, your interests
matter. But, will still communicate that the child is being listened to. (AC01)
However, two comments suggested that responsiveness was not always considered an
appropriate skill to train. One participant remarked on the child-centred nature of responsiveness,
which she found to be incongruent with Vhavenda culture.
Some considerations that the researcher would need to take into account when training
caregivers on responsiveness were also highlighted by the participants in the interviews. In
addition to achieving the main goal of communication using responsiveness as a strategy, one of
the participants suggested that activities should focus on fulfilling basic needs as opposed to
prioritizing play activities. This was illustrated in the following quote:
In a child’s focus world, that would be appropriate, but in many traditional society, the
child is not the centre of everyone’s attention, so there would have to be other way of

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responsiveness, but (that) will still communicate that the child is being listened to …I
think one would have to probably prioritize basic needs rather than… you know…
something like hugging a toy. (AC01)
Creating communication opportunities was described as appropriate by most participants.
However, some concerns were also raised about this strategy. For example, participants reported
that it might not be culturally appropriate to offer choices to the child, as it might be interpreted
as spoiling the child.
I feel like it is appropriate and it would be a good way of teaching the children how to
communicate. I noticed on the video when the parent was holding both the banana and
the apple that the child was forced to choose what he wanted and that made the child
point at the fruit which they wanted. (EL04)
Culturally, they may feel like you’re spoiling the child. They may ask you why you are
giving the child so many things at once and suggest that you are wasting food. (AC02)
Modelling aided language input was reported to be appropriate for use by Vhavenda
caregivers.
Yes, it’s going to help by that way, it will help because when you have a child who cannot
speak, it’s difficult, so using pictures is good. The child can point and show you what they
want. They can also come tell you I want this, I want that. Yes, it will help. (PA01)

5.11.3.2 Training
The researcher enquired about how training can be made acceptable to Vhavenda
caregivers. The participants provided suggestions on how to go about training, how the
researcher can make training acceptable, what parents can be trained on and how the trainers
should handle themselves. Participants suggested that the researcher should always find out what
the participants are currently doing in order to learn from them and build on their expertise. Also,
the researcher needs to establish the caregivers’ levels of literacy and match the training to their
context. The objectives and outcomes of the training should be clearly stated by the researcher.
The benefits of using the strategies should also be clarified. It is also vital to establish caregivers’
interest in the programme beforehand. Regarding the training approach, participants suggested

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that the researcher needs be aware of challenges she might face, for example if caregivers feel
that they are being stigmatized rather than being assisted.
Some of the problems include the fact that some of the parents may feel like they are
being taught juvenile and childish stuff. With that being said, a parent whose child has a
communication disability and wants by all means to be able to communicate with their
child, will take these teachings to heart so that they may be able to communicate with
their child without any issues. (EL04)
Regarding training suggestions, the following examples were outlined:
I think it’s always useful to get a sense about what they’ve been doing in so long, you
know, like get a way of getting them to tell you what they’ve been doing up to this point so
that they can share some of their own innovation, you know, because it’s possible that
they maybe be approaches that… you know… family on their own sort of design that we
can tap into. (AC01)
I think that the first thing is how you introduce yourself. Secondly, maybe that how will
you approach them and then thirdly, I think yes they’ll accept you cause they know they
are going to benefit out of it to be taught how to look after their kids, how to
communicate with their kids cause if you look at it, is not all of us, that are proud and
bold in such a way that we show off our children with disabilities. (PA01)
Content suggestions were made by some participants. They suggested that the content of
the training should include teaching caregivers to exercise patience when interacting and
communicating with their children. Furthermore, the participants suggested that debunking some
of the cultural beliefs regarding the cause of disability and being cognisant of the audience
regarding their faith and beliefs would be important when training.
The parents need to be taught first that they must be a bit more patient and understanding
when it comes to the young child. This will help them know what to expect from the child
and in turn, lead to them being a lot more understanding and lenient towards the child,
which will help the child learn and develop in a much better way.” (AC02)
They further suggested that, most importantly, the researcher would have to be sensitive
to the culture and beliefs of the caregivers when developing content. To add onto the content
suggestions, participants also alluded to how the researcher should handle herself. They
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suggested that researchers should treat training of caregivers with sensitivity as the potential
participants could be very sensitive.
Cultural sensitivity was another facet raised by some of the participants. They alluded to
the fact that a balance needed to be maintained between being culturally relevant and using skills
that have been proven to work.
…so, ok, if you are go(ing) to work with the rural people, you need to be very sensitive
because people living in rurals, they still follow culture and tradition a lot. Whether that
person is educated or not, whether that person is a Christian or not, but some of the
cultural practices they are still following them. It means when you go to that family, try to
find out by all means if they are still following culture, but by not directly asking them,
while you are speaking to them, you will be able to pick up that this is a Christian who
still follows Tshivenda cultural practices… You should also be cognisant of that too. It
helps you know how to address them depending on what they are inclined towards. If it
happens that when you are talking to them, and note that this is a full Christian, you
know that I am going to use Christian route and western route. Then if you pick up that
this person mixed, when you charter the Christian territory you need to be extra careful.
Let’s say I do not mix with Christianity, and you are talking about that my religious
inclination is demonic, I will not listen to what you will say to me. yes, because you are
crushing my belief. (EL03)

5.11.3.3 Materials
During the interviews, participants were provided with videos that demonstrated the use
of the suggested strategies. A communication board was also provided to explain how to model
aided language input. Participants provided input on the appropriateness and cultural sensitivity
of the materials, and also provided suggestions. Overall, the participants indicated that the
materials provided to them were appropriate. However, some of the materials that were
considered inappropriate included the use of dolls as illustrated in one of the videos.
Yah. Because during… in our culture we do not have dolls… we do not use dolls. (EL01)
Some suggestions for materials were around aligning the material to the contexts,
environment and the caregivers. The participants indicated that videos and communication
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boards should show African black people because Vhavenda are sensitive. Therefore, it would
help people to feel included and would allow them to relate to the material if black African
people were used. Some of the participants reported on the videos, communication boards and
materials used in the videos. This was illustrated in the following quotations:
I think it will be appropriate to use black African people. (EL03)
Furthermore, when it comes to providing children with food choices (shown in one video,
where a child chose between an apple and a banana), they suggested that caution needs to be
practiced and choices should be discussed with caregivers beforehand. When planning for an
interaction between a child and a caregiver, it is important to take note of how certain things are
modelled using toys. For example, the child showing affection to a doll might not be ideal for the
Vhavenda culture as indicated by one of the participants:
Yah so I think in traditional context, affection is shown to other humans before anything
else. And then the second thing that I’m picking up from the video is the… that thing of
connection, what does the doll represent? A doll represents something that I can show
affection to and culturally, inanimate objects such as dolls in a rural context is a difficult
one. That’s why you find some dolls without legs. (AC01)
One of the participants suggested that specific activities should be chosen for specific
interaction partners. She suggests that play activities be set up for children and their playmates.
Activities around meals should be done with parents as food is central to the Vhavenda culture.
So, for other interest such as play interest, I would focus more on other children if there
are possibilities for that… Something that would make sense to almost every parent …
rotates around food, right? (AC01)

5.11.4 Theme 4: Changes over time

Participants reflected on changes they had observed over time. These changes related to
the way in which parents and children interact, beliefs about disabilities, as well as comments
that differentiated modern and traditional practices. Overall, these comments indicated an
orientation amongst many participants that culture was not set in stone, and was ever-evolving.
This was a marginal theme, and for this reason, only six codes were identified, with no
subthemes or categories, as depicted in Table 5.11.
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Table 5.11
Theme 4: Changes over Time
Code example Frequency
Acceptance of the child 1
Changes in beliefs 5
Changes in practices 6
Perceptions of changes in era 6
Changes in communication partner 1
Child safety 1

Some of the participants indicated that the beliefs about disability are evolving as the
times change. They attributed this partly to the fact that people are accessing formal education,
which leads to an understanding that they can get medical care for their children. They also
mentioned that people adhering to the Christian faith believe that every child is a gift from God.
The noted a change in beliefs - from witchcraft causing the disability to the Christian beliefs of
the child being a gift in the modern era. This was reported by some of the elders, for example:
…but nowadays people are now educated. They know how doctors work and they take the
child to the doctor. (EL01)
Because of Christianity, since most of us now are practicing Christian religion, we
believe that this is a gift from God. Yeah, even though they are still some of the people
who maybe are not Christians, because we cannot believe on the same thing some of us
believe on African religions, so some of them feel that no, which culture play the role
here, but really few of them, most of us nowadays because of Christianity, whether a child
is disabled or fine, we believe that this is a gift from God…back then people were afraid
of witchcraft and nowadays they are afraid of the witchcraft notion. (EL03)
Parents seek help from various avenues and at present they can choose to see doctors and
health professionals, whereas this was not always possible in the past. In recent times, caregivers
are able to find resources that can help them with their child with a communication disability.
These resources are readily available to them in the form of health professionals, spiritual leaders

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and also traditional healers. Some participants suggested that awareness of medical options was
linked to obtaining formal education.
Yes, because nowadays, there are so many resources that we can use, you know to assist
the child, , and, and most of the parents nowadays are being educated. (EL03)
Also, acceptance of children with communication disabilities is on the rise as reported by
EL03: “ehm, I think nowadays its better, …most of the parents are starting to accept their
disabled children; but during those days it was so difficult".
Helpers are recognised as communication interaction partners for children nowadays as
stated by (AC01): "and in the new world that we live in, there are families that has a helper and
the helper will be that person that actually spends more time with the child." As, some parents
work full time and grandmothers do not stay with them in nuclear families, most parents hire
domestic workers to take care of the child on a day-to-day basis.
The participants further indicated that there should be consideration of which one is
important for the caregivers, be it a modern or traditional cultural approach; and that the focus
should be on helping the child communicate over respecting culture.
Another thing that we must keep in mind is that the focus here should be on helping the
child to communicate, not to respect the culture and tradition whilst the child cannot
communicate with others. (AC02)

5.12 Implications for the development phase

In an attempt to explore appropriateness and acceptability of proposed strategies that
stemmed from the scoping review, participants reported that all three strategies were appropriate,
but also had suggestions as to how they can be made more appropriate for the targeted
participants of the training.
Participants were asked about their perceptions of the Vhavenda pertaining to
communication disability. In order for any intervention programme to be successful, it is
important for the researchers to understand the knowledge, perceptions and practices of the
targeted population (Boateng et al., 2017). In this regard, there were factors that were noteworthy
such as beliefs regarding the causes of a (communication) disability, help seeking practices based
on the beliefs, interactions between caregivers and children, how interactions happen and how
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children with (communication) disabilities are raised. However, some changes in practice and
perceptions were noted based on the changes in era and belief systems of Vhavenda, which the
researcher would have to be aware of in order to avoid stigmatization or any form of
discrimination against the participants. These factors informed some of the content that was
included in the caregiver training programme developed and also guided ethical conduct.
Caregivers were asked about acceptability of the strategies that the researcher proposed
to include in the training programme that emerged from the scoping review. It was interesting to
see how the strategies were mostly considered acceptable, though the activities presented during
the interviews to illustrate the strategy garnered some critique regarding their appropriateness for
rural communities. The researcher therefore considered this in the development of the
programme, for example, in preparing video clips to illustrate the strategies using activities that
were culturally appropriate and acceptable as per the suggestions provided by the participants.
In addition to the strategies, participants suggested how training should be executed and how the
researcher should behave during training. These suggestions were implemented during training
so as to enhance the cultural appropriateness and social validity of the training.

5.13 Summary
The main purpose for conducting the interviews with Vhavenda cultural stakeholders was
to explore how typical interactions between caregivers and children occur. In exploring typical
interactions, it was pertinent to understand the interaction partners, activities that children engage
in, the purpose of interaction, topics that are communicated about, other modes of
communication used in communication, and how interaction happens. This translated into the
inclusion of culturally and contextually relevant activities within the programme as well as
excluding those that are considered taboo and those that do not stimulate communication
interaction; seeing that the programme was aimed at training caregivers to implement AAC
strategies that would foster communication and interaction with their children with CCN.
The results of the cultural interviews revealed activities that Vhavenda children and their
communication partners engage with in daily interactions. Activities were categorised according
to those that are rich in communication and those that do not involve communication. Activities
during which communication is prohibited were also mentioned. Topics that are communicated
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about as well as the importance of communication were described. Furthermore, other modes of
communication that are used by Vhavenda other than speech were stated. To add onto these
revelations, perceptions of and beliefs of Vhavenda about communication disability, how
communication transpires between caregivers and children with communication disability, help
seeking practices of caregivers in relation to the type of help, expectations thereof and reasons
for help seeking were also explored. Additionally, how caregivers and children with
communication disabilities interact was discussed. Participants noted differences in
communication and interaction between children with (communication) disabilities and their
typically-developing peers.

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CHAPTER 6
PHASE 2: DEVELOPMENT OF THE CAREGIVER TRAINING PROGRAMME

6.1. Introduction
This development phase chapter explains the design, development and piloting
of the custom-made caregiver training programme (CgTP) to be implemented in
Phase 3 of this study. Figure 6.1 shows the schematic representation of three phases of
the study that followed in a sequential manner. The focus of Chapter 6 is, however, on
the development phase (Phase 2).
Figure 6.1
Overview of Methodology

PHASE 1: EXPLORATORY PHASE

Sub-study 1: Scoping review (Chapter 4) Sub-study 2: Cultural Stakeholders' interviews

A scoping review was conducted to describe (Chapter 5)
studies on programs designed to train caregivers of Interviews were held with 10 stakeholders (four
young children with CCN to implement AACs. elders, three academics and three caregivers of
The aim of the review was to identify and describe older children with CCN) in order to identify
the participants of the training programs, the cultural practises and beliefs of Vhavenda with
training context, content, instructional methods, regards to caregiver-child communication
materials, as well as scheduling and delivery interactions and children with communication
format. The outcomes and measures used to disabilities, while also eliciting opinions about the
evaluate these were also summarised. This proposed training. This information ensured
information guided the program development cultural congruity of the training programme
(Phase 2). developed in Phase 2

PHASE 2: DEVELOPMENT PHASE (Chapter 6)

Initial Programme Expert Review Pilot Study
Development One caregiver-child dyad who met all
The Caregiver Training Five SLPs practicing in Vhembe the selectin criteria took part in the
Programme was developed based participated in the review process. The pilot study. A single case multiple
on findings from the Exploratory SLPs gave input on the logistics, probe design (A-B design) was used
Phase (Phase 1). Preliminary objectives content, activities, materials, whereby baseline measures were
procedures for implementation practicality and usability for the taken, after which the caregiver was
were also developed, as were Caregiver Training Programme . The trained. Intervention and maintenance
materials for screening and training program and proposed measures were also obtained. Based on
measurement. procedures were then amended based on the findings, amendments were made
the input obtained from the expert to the program, procedures and
review process. The SLPs provided input measurement instruments for the main
on the relevance, appropriateness, and study.
potential effectiveness of the CgTP.

PHASE 3: EVALUATION PHASE (Chapter 7)

A single case multiple probe design across
participants with three caregiver-child dyads was used to
evaluate the effectiveness of the Caregiver Training
Programme. Maintenance of skills three weeks post-training
was also measured. Thereafter, the three caregivers also
completed a questionnaire with closed and open-ended
questions was used to evaluate the social validity of the
training program. 106
 Chapter 6: Development Phase

The chapter commences with an overview of the aims of the development phase.
Secondly, an overview of the development of the programme is provided. The framework
that guided the development process is explained. Thereafter, the different sources of input
that informed the programme are explained, namely theory, as well as the data gathered
from Phase 1 (exploratory phase) of this study which comprised of a scoping review and
Vhavenda cultural stakeholders’ interviews. Thirdly, and overview is given of the initial
programme content and materials. Fourthly, the expert review and pilot study are described
as well as the resulting amendments made to the programme. Lastly, implications of this
phase for the evaluation phase are discussed.

6.2. Aims of Phase 2

6.2.1 Main aim of Phase 2
The main aim for the development phase was to design and develop the CgTP,
screening tools and measurement material for Phase 3 (Evaluation Phase) of the study,
based on the data gathered in the exploratory phase.

6.2.2 Sub-aims of Phase 2

In order to achieve the main aim of this phase, the following sub-aims were
formulated:
(i) To conceptualise and develop the CgTP and all materials required for its
implementation;
(ii) To ensure relevance and applicability of the CgTP through an expert review
involving SLPs practicing in Vhembe district;
(iii) To develop appropriate materials for screening of potential participants,
measurement of dependent variables, checking of procedural fidelity, and
obtaining caregiver feedback post-training in order to appropriately evaluate
the implementation of the CgTP; and
(iv) To determine appropriateness of all the materials and procedures proposed
for the implementation of CgTP and the evaluation of its effect on caregivers
(as conducted in Phase 3) by conducting a pilot investigation.

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6.3. Overview of the development of the caregiver training programme

The overall development process was guided by the Design and Development
paradigm by Thomas and Rothman (1994). The actual programme (content, instructional
methods chosen, materials, etc.) was conceptualised based on various sources of input,
including (a) theories of child development, (b) adult learning theory and (c) the findings
from Phase 1. The sub sections that follow explain first the process (steps) that were followed
in the development, and second, how various sources of input informed the actual
programme.

6.3.1 Design and Development paradigm (Thomas and Rothman, 1994)

Thomas and Rothman's (1994) Design and Development paradigm was used to guide
the process of programme development. This model provided important guidelines that form
the basis of a systematic conceptualization of designing and developing training. Thomas and
Rothman (1994) suggested six steps when designing training programmes. These steps
include: (a) problem analysis and project planning, (b) information gathering and synthesis,
(c) program design, (d) early development and pilot testing, (e) evaluation and advanced
development, and (f) dissemination. The steps are described in Table 6.1 with regards to how
they were implemented in this study. Step A (problem analysis and project planning) and Step
B (information gathering and synthesis) were carried out and discussed in Chapters 1, 4 and 5
of this study. This chapter focuses on Step C (programme design) and Step D (early
development and pilot testing).

Table 6.1
Steps Used to Develop the CgTP (adapted from Thomas and Rothman, 1994)
Steps of design and Description of the steps for the current study
development
Step A: Problem analysis and The background and problem statement as well as the broad project
project planning planning were outlined in Chapter 1 of the dissertation.
Step B: Information gathering This step was conducted in the exploratory phase of this study. A scoping
and synthesis review was first done followed by interviews with Vhavenda cultural
stakeholders. These were conducted sequentially as shown in Figure 6.1.

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Steps of design and Description of the steps for the current study
development
The scoping review contributed to identifying an instructional protocol
that was adapted for this study which has components that are evidence-
based and have been shown to be effective when training communication
partners (Kent-Walsh & McNaughton, 2005). The components of the
instructional protocol are discussed in detail in Section 6.4. Furthermore,
the review analysed the content of caregiver training programs, the
instructional strategies used and the outcomes that have been measured
for the caregiver and child. The researcher then took this information and
incorporated it into the instructional protocol to design the prototype of
the programme. The researcher also identified some potential caregiver-
implemented intervention strategies and presented these to the
stakeholders in the stakeholder interviews, for validation and comment.
During the interviews, stakeholders gave rich information on typical
adult-child interactions, Vhavenda cultural views about communication
disability and intervention, and commented on the applicability of the
provisionally proposed intervention strategies.
Step C: Programme design From the results of the scoping review and the cultural stakeholders’
interviews, a prototype of the custom-made CgTP was designed.
Step D: Early development Training material was presented to SLPs practicing in the five hospitals
and pilot testing from which participants were recruited. The SLPs were requested to give
input on the logistics, objectives content, activities, materials, practicality
and usability for the CgTP. The experts received an invitation from a
shared Google drive created by the researcher which had the CgTP
materials (PowerPointTM presentations, booklet and communication
boards). From the expert input with SLPs, the researcher modified the
materials based on the suggestions and feedback received from the
experts.
The researcher then conducted a pilot investigation with one participant
who did not form part of the main investigation. The pilot investigation
was done to evaluate the appropriateness and feasibility of all the
materials and procedures proposed for the evaluation of the programme.
Based on the results of the pilot investigation, the researcher made
changes to the training materials, procedures and measurement
instruments accordingly.
Step E: Evaluation and The researcher evaluated the effect of the custom-made CgTP in Phase 3
advanced development using a single case multiple probe design across participants. Details are
discussed in Chapter 7 (Evaluation Phase) for Phase 3. Suggestions for
additional advanced development of the programme are made; however,
these were not implemented as part of this study.

6.3.2 Input that informed the CgTP

Theoretical underpinnings that guided the development of the CgTP emerged from
various entities. Some theories were from the field of language development and were
concerned with how caregivers can influence communication development of their children.
Furthermore, other theories that will be discussed in this section are those pertaining to how
adults learn, which will guide the instructional approach of the CgTP. Input from the
exploratory phase will be discussed in relation to the content and material of the CgTP. Figure
6.2 shows an overview of the various sources of input that influenced the development of the
programme.

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Figure 6.2.
Input That Informed Development of the CgTP.

6.3.2.1 Theoretical underpinnings of programme content

The researcher chose the transactional model of development, eco-cultural theory and
the interpretation of Vygotsky’s cultural historical perspective in relation to how children
develop communication using alternative means. Additionally, the theorists posit the tenets of
the theories on how communication development happens in a dyad and how the members of
the dyad are influenced by each other in the environment, though Renner (2003) applied the
cultural historical perspective on children with a communication disorder. The eco-cultural
theory is concerned with the caregiver and the cultural context, as well as the usefulness of
everyday routines. The transactional model talks about the reciprocal influence within the
parent-child dyad and the relationship that exists between the caregiver and the child within a
particular context.

(i) The development of communication with alternative means from Vygotsky's cultural
historical perspective (Renner, 2003).

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Vygotsky proposed that children develop communication skills through a process that
is socially mediated. Thus, a child requires an adult, a knowledgeable member of their society
for them to attain communication skills, acquire cultural beliefs, values and so forth. Renner
(2003) applied Vygotsky’s cultural historical perspective to children in need of AAC. The
author outlined how augmented communication development can be facilitated for children
with CCN during caregiver-child interactions in daily routines. Firstly, Renner highlights the
need for and legitimacy of implementing AAC. Vygotsky advocates that children with
impairments (in this case CCN associated with developmental disabilities) should be afforded
social contact in the same way as children without disabilities. The child should be afforded
the same opportunities for social contact regardless of their disability. Therefore, the
disability is seen to emanate more from the reaction of the environment than the child’s
functional limitations, in line with the social model of disability (Oliver, 2013; Samaha,
2007). In order to optimize the development of a child with CCN and overcome the disability,
there is a need to create side-tracks of enculturation. These side-tracks can be created by
substituting one mode with another but maintaining the same functions. In this case, in order
to mitigate the limitations or lack of speech and language, Renner advises that speech can be
substituted using AAC.
Secondly, Renner emphasised the importance of modelling. According to Vygotsky,
children are reported to interact with experienced members of the social environment
(caregivers or older children). These skilled individuals then model forms of culturally
appropriate skills. Through guided learning, children learn and master skills with the help of
the experienced models. Thus, when the adult models model the use of AAC, then the
children will learn how to use AAC.
Thirdly, Renner’s application suggests that such modelling should take place in daily
routines. The family should provide an environment that is conducive for the child’s
development. Therefore, when aided language input is integrated in the daily routines of the
children by their caregivers, children with CCN will learn to use AAC in a communication
environment that supports and promotes their communication skills. Vygotsky’s theory as
interpreted by Renner (2003) therefore supports the implementation of AAC in natural
environments, through knowledgeable others (like parents and caregivers) modelling its use
for their children with CCN.

(ii) Transactional model of development (Sameroff & Fiese, 1990).

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The transactional model by Sameroff (1975) argues that development in an

individual is shaped by their interaction with the environment. This suggests that
developmental outcomes do not result as a function of the individual. Thus, child
development is seen as a result of the continuous dynamic interplay of the child and the
experiences afforded by his/her family and the social context. This model is grounded on
the bidirectional effects of the caregiver-child transactions and the environment (Sameroff,
1975; Sameroff & Chandler, 1975; Sameroff & McKenzie, 2003). The model posits that
child development is influenced by the environment and vice-versa (Sameroff & Fiese,
1990, 2000).
For this reason, parent-mediated interventions are reported to be bi-directional in
nature (O’Toole et al., 2016) due to the interplay between the adult (caregiver) and the
child. Thus, when verbal or non-verbal communication from the child increases, the adult
responds, and as the adult responds, the child will also increase their communication. In
other words, when the caregiver responds accordingly to the child’s communication
attempts, the child will continue to initiate communication attempts, however if the
caregiver does not respond accordingly, the child’s communication attempts will be
restrained. However, if the caregivers of a child living with disabilities and CCN reduce
their interactions with the child, assuming that the child is not capable to interact with them,
this will not foster communication development for this child.
Therefore, caregiver education (referred to as training in this study) has been
reported to yield positive results in some behaviours and symptoms in children. Caregiver
education has also been shown to yield positive results for families as well for caregivers
who participate in parent education programmes (Brookman-Frazee, 2004).

(iii) Eco-cultural theory (Bernheimer, Gallimore & Wiesner, 1990)

The eco-cultural theory argues that the family socially constructs child activity
settings to accommodate the needs of children within the family environment (Bernheimer et
al., 1990). Furthermore, the theory posits that family members are more likely to implement
and sustain interventions that fit into the daily routines of the family and those that yield
positive outcomes for the family as a whole, as well as those that are in line with the parents’
objectives and beliefs. Components of the eco-cultural theory are necessary to incorporate in
intervention planning because it increases the “contextual fit”, pointing out that interventions
for young children should fit into the daily routines of a family and be incorporated therein

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(Brookman-Frazee, 2004). Interventionists need to build on the strengths of the family and
what the family is already doing rather than bringing in new concepts and forcing them onto
families, because these new concepts might not build on their strengths and what they know.
The concepts might not be culturally appropriate and contextually relevant. This might lead
to interventions not being accepted by the families they are intended for. In the current study,
the CgTP development was informed by stakeholder input and validated by an expert review
before implementation. Also, caregivers chose the daily routines during which they wanted to
implement the communication strategies.

6.3.1.2.3 Adult learning theory (Knowles et al., 2005)

Adults are reported to learn differently from children (Knowles et al., 2015) in that
they bring experience to the learning task. Therefore, adult learning principles should be
adhered to when teaching adult learners. These principles have been widely used in training
various stakeholders in the health and education sector. Knowles et al. (2015) revised the
principles and condensed them to the following: (a) adults display a need to know why they
should learn; (b) adult learning is driven by their motivation to problem solve; (c) training
approaches used must match the background of the adults; (d) active involvement of adults in
the learning process is key. Table 6.2 shows how the four adult learning principles as outlined
by Knowles et al. (2015) will be applied in this training programme.

Table 6.2
Application of Adult Learning Principles to the Proposed CgTP
Principle Application to the CgTP delivery
Adults display a need to The researcher will describe the rationale for the CgTP.
know why they should Caregivers will be given information letters outlining the
learn investigation, including an explanation of why it is important to
conduct the investigation. The researcher communicated the
objectives of the different topics that were outlined in the
presentations.
Training approaches used The programme was designed from the data collected from the
should match the scoping review and stakeholder interviews. Training material was
background of the adults designed to accommodate caregivers with low literacy (Grade 4
minimum level) from a Tshivenda language and cultural
background. The training materials were provided in both
English and Tshivenda. Presentations that were used for the
caregivers included pictures and videos that were adapted to be
contextually relevant. The researcher used videos that had share-
alike creative commons licensing and were approved by the
cultural stakeholders during the interviews. Also videos from
clinical training that parents consented to for the use of training
from the clinic data repository will be used for the training. The
clients and caregivers’ faces will be blurred on the videos for

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Principle Application to the CgTP delivery

confidentiality purposes. Verbal descriptions and demonstrations
were also used.

Adult learning is driven by All of the caregivers had a child with CCN and the training was
their motivation to aimed at helping them solve communication problems they
problem solve experienced with their child. Training was aimed at helping them
gain practical skills that they could implement directly with their
child. Furthermore, they engaged in tasks where they able to
apply their learning directly to themselves and their child by
reflecting on their practices and applying their learning to
propose possible solutions to the communication challenges they
were experiencing with their child. During guided practice,
caregivers were shown videos of their interaction with their child,
and were asked what they thought went well during their
interaction; what they thought they could have done differently;
and how they could improve in the next session.
Adults learn through Caregivers will be actively involved in various activities
doing throughout the training. Caregivers will reflect on the daily
training using a video or audio recording which they will send to
the researcher. At the end of the two-day training, they will be
asked to record a video of themselves teaching another adult the
strategies using mnemonic, explaining each of the strategies
described by the mnemonic and how to implement the strategies.
The caregivers will have ample opportunities to practice
implementing the strategies they were taught (offering
communication opportunities, contingent responding and aided
language modelling) during the guided practice sessions. Each
recording will be followed by a feedback session to further guide
their implementation.

6.3.2.2 Input from the exploratory phase

Table 6.3 shows the input towards programme development from the scoping review
and cultural stakeholders’ interviews. Input was discussed based on its contribution to
participant selection, training context, instructional methods, training material, logistics and
scheduling, outcomes and measures used.

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Table 6.3
Input from Exploratory Phase to Programme Development

Aspect Description with reference to findings from the scoping

considered review and/ or interviews with cultural stakeholders
Participants From the review evidence was found of previous successful
caregiver training conducted with caregivers from low- and
middle-income contexts and also rural contexts. Caregivers
were trained to implement AAC with their children during daily
activities. Gona et al. (2014) and Bunning et al (2014) reported
on a home-based intervention and teaching caregivers in rural
contexts of Kenya to implement various aided and unaided AAC
systems. Results of this investigation showed that caregivers had
positive experiences with the training as it was tailor-made for
them, and that they could see positive outcomes when
communicating with their children using AAC. However, no
studies entailing training programs for South African caregivers
were found.

From the stakeholder interviews, the caregivers who interacted

with children were mostly mothers, grandmothers and other
family members. In this study, caregivers were therefore not
limited to mothers only, but they could be any person other than
the parent who is taking care of the child and responsible for
carrying out care-giving tasks on a daily basis (Children’s act
38, 2005). The participants were caregivers of children with
CCN receiving SLP services at a hospital in Vhembe; they
should speak Tshivenda as their home language; they should
have at least a grade 4 level of literacy (reading and writing) in
Tshivenda or English; However, one condition that was imposed
was that caregivers should be older than 18 years. This decision
was made to simplify caregiver consent.
Training A total of 13 of studies in the scoping review reported that
context intervention was done at the children’s homes, although two of
the 13 studies had a clinic and home component. Furthermore,
the majority of the studies employed individual face-to-face
training, although one study employed both group and
individual sessions. The caregivers in this study were trained
individually face-to-face in their homes by the researcher. Due
to Covid-19, the researcher maintained social distancing of at
least 1 to 2 metres from the caregivers, they wore a mask
throughout and sanitized frequently. The CgTP had the potential
of being implemented using synchronous telehealth practices if
there were further lockdown restrictions.

From the scoping review, caregivers interacted with children in

mealtime, play and educational activities (i.e. reading books).
During the cultural stakeholders’ interviews, it was reported that
Vhavenda children communicate and interact with their
caregivers in various daily routines. These daily routines include
parent-led chores, child-led activities and also play.
Training In the scoping review, it was found that most studies trained
content caregivers to implement specific strategies to implement with
their children. This is understandable, as caregivers need to
change their behaviour in order to change the behaviour of their
children. However, a knowledge component was also observed
as part of some of the trainings. For example, the ComAlong
Programme (Ferm et al., 2011; Jonsson et al., 2011) provided

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Aspect Description with reference to findings from the scoping

considered review and/ or interviews with cultural stakeholders
background information about communication, AAC and using
AAC at home. One of the andragogical principles by Knowles et
al (2005) states that adults need to know why they should learn.
Providing background information on these topics can help
them to understand the significance of AAC in addressing
communication barriers. However, a change in knowledge does
not necessarily result in behaviour change. According to Powell
and Dunlap (2010) a behavioural orientation in training is a
characteristic of an effective parent training programme. The
current programme was therefore designed to incorporate both
knowledge and skills (behavioural) aspects. The knowledge
component focused on educating caregivers about
communication and its importance; AAC and the various
systems and the strategies that facilitate communication
development. The skills (behavioural) component focused on
three strategies, namely contingent responding, offering
communication opportunities and modelling aided language
input. The specific behavioural strategies, were chosen as they
are widely used in the field of AAC as indicated in the scoping
review with intentional informal communicators in order to
move them to becoming formal communicators using AAC. In
some cases these strategies were used with beginning
communicators. The scoping review also indicated that these
strategies had been socially validated through caregiver input
either before or after training.

Cultural stakeholder interviews: the stakeholders were requested

to provide input on the proposed three strategies’ cultural
appropriateness. They reported that all three strategies were
considered appropriate and acceptable, although one participant
remarked on the child centred nature of responsiveness, which
she found to be incongruent with Vhavenda culture. Overall,
they were considered culturally appropriate.
Instructional From the scoping review, it was found that the instructional
methods protocol on training communication partners by Kent-Walsh and
McNaughton (2005) was used in a few studies to train parents.
It was adapted and used for this study (see Section 6.4). This
instructional protocol comprised of instructional strategies that
have been reported to be effective in parent training.

Instructional strategies such as verbal rehearsal, live

demonstrations, modelling, strategy description, use of written
materials, homework, controlled practice with feedback,
videotaping parent-child interactions with feedback and video
demonstrations were used in this study during parent training.
Furthermore, reflection and commitment to strategy were
employed in this study although these strategies were used less
in studies in the scoping review. Commitment statements are
important in intervention as they are a motivation to the
participant to maintain new behaviour (Lokhorst et al., 2013).
They are a visual reminder that influences changes in one’s self-
concept to align with new behaviour. They are valuable in
motivating changes in cognition, values and attitudes towards
the new behaviour learnt (Cialdini, 2001 as cited in Lokhorst et
al., 2013). The pre and post commitment statements are
significant in this research as it has been done in other studies
and was used in other fields for continuing professional

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Aspect Description with reference to findings from the scoping

considered review and/ or interviews with cultural stakeholders
development (Bornman & Louw, 2019) and environmental
interventions (Lokhorst et al., 2013) that when participants sign
off or create their own statements, they are motivated to learn,
change behaviour and use the newly learned behaviour.
Reflection is an important aspect in the learning process as it
affords the adult learner the same power that experiential
learning affords them. This happens when an adult learner is
able to articulate their thoughts about what they are learning
about. This study will include reflective exercises for the
caregiver after each session wherein they will log their thoughts
about the session and what they have learnt using a video or
audio.
The rest of the strategies mentioned above have been
recommended as significant in training parents also in low
socio-economic contexts (Barlow et al., 2012; Engle et al.,
2011).

From the cultural stakeholder interviews, the stakeholders

suggested soft skills that the researcher should take into
consideration such as: treating caregivers with respect; take
culture into consideration, respect their beliefs and being aware
of the participants’ beliefs in order to find a way to address
them. The researcher noted all the suggestions and endeavoured
to implement them in the training,
Training The scoping review showed that the use of lectures, manuals and
material video demonstrations were employed in some of the studies.
Therefore, the materials of the training programme developed for
this study included MS PowerPoint ™ 2019 presentations that had
videos embedded to depict the strategies, a training booklet and
examples of communication boards. The researcher developed a
training booklet for the caregivers to refer to as the need arose.
The materials used in this study were adapted to accommodate
individuals with lower literacy levels because the participants in
the review had higher levels of education.
The review also revealed that parents were trained to implement
various aided and unaided augmentative and alternative
communication systems. For this study, however, children with
mild fine motor difficulties were not excluded, thus it was decided
to use communication boards rather than an unaided system such
as key word signing. The proposed programme will train
caregivers on how to use aided language input using
communication boards. Additionally, for the current study, aided
modelling was chosen as option as low technology boards with
PCS symbols: 1) are a symbolic form of communication- aim is to
move kids to more symbolic forms; 2) boards do not require intact
fine motor skills; 3) are relatively inexpensive and therefore
appropriate for resource constrained settings. It was observed
from the scoping review that low technology AAC systems were
used in LMICs with participants that have not yet been exposed to
AAC before because they are cost effective (Bunning et al.,
2014). Thus, researcher chose the use of communication boards
for this study.

The choice of vocabulary and symbols was influenced by the

results obtained from the stakeholders’ interviews. The
stakeholders reported that it is important to use materials that
speaks to Vhavenda culture and context (i.e., individuals and

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Aspect Description with reference to findings from the scoping

considered review and/ or interviews with cultural stakeholders
objects should be representative of the culture and context)
because if materials do not talk to them, this might pose a threat
for acceptance of the training as Vhavenda are sensitive about
their culture.

During the stakeholder interviews, participants were given a

communication board of a mealtime activity. Stakeholders gave
suggestions on how to make some of the of the vocabulary and
picture items more culturally appropriate. For example, the
stakeholders suggested modifications to the symbols on the
communication boards should portray people of color [black
Africans] as well as contextually relevant stimuli for Vhavenda
(e.g., using a basin to bath not a bathtub). Also, the symbol that
represented an adult should be that of an adult and not of
someone who does not look like an adult. The preliminary
communication boards shown to stakeholders were amended
according to the feedback obtained before undergoing expert
review.

Logistical Scheduling: The studies in the scoping review that reported on

planning the frequency of training sessions showed that sessions were
and conducted weekly, monthly or twice a week. The duration of the
scheduling training reported ranged from 75 minutes to 16 hours in total. In
the current study, an initial training of 8 hours (delivered over
the course of two days) was followed by eight guided practice
sessions of about 45 minutes each. It was surmised from the
scoping review that this length and frequency of training could
realistically induce a change in behaviour.
Delivery format: From the review, only one study reported on
the use of online training with caregivers, while the remaining
studies implemented face-to-face training. The current
programme was designed for face-to-face individual training.
However, it had the potential to be adapted to work for group
training and using online methods. Due to the Covid-19
pandemic, the researcher decided to have the programme
designed in such a way that it would be easy switch from face-
to-face to online methods due to the unpredictability of the
situation with the pandemic.
Outcomes From the scoping review it became clear that in most studies
(DVs) and both the parent and the child outcomes were reported. In most
measures studies, behavioural outcomes were measured. Regarding
used caregiver outcomes, contingent responding or responsivity was
reported in seven studies; creating opportunities also in four
studies and providing augmented input in the majority (n = 15)
of the studies. These skills/strategies were then presented to the
cultural stakeholders, who indicated that they were appropriate
for caregivers and that they would assist the caregivers.

The caregivers who participated in this study were therefore be

measured on the following outcomes (dependent variables):
- Frequency of caregiver’s responses to child in a 10-
minute interaction during a daily activity.
- Frequency with which the caregiver offers
communication opportunities in a 10-minute
interaction during a daily activity.

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Aspect Description with reference to findings from the scoping

considered review and/ or interviews with cultural stakeholders
- Frequency with which caregivers model the use of
aided language input in a 10-minute interaction during
a daily activity.

Regarding child outcomes, a total of 13 studies reported on

pragmatic outcomes, such as frequency of turn taking and
frequency of initiation. In this study, concomitant outcomes
(DVs) for the child will also be pragmatic skills, namely:
- Frequency with which the child takes communicative
turns in a 10-minute interaction during a daily activity.
- Frequency with which the child uses augmented output
in a 10-minute interaction during a daily activity.

The concomitant outcomes were measured in this study because

of the transactional relationship that exists between the caregiver
and the child in a particular context. Though caregivers will be
trained, it is of paramount importance to see the outcomes in the
child as they are trained to make a difference in the child’s
communication in this case. Thus, this will reveal the
hypothesised nature of influence the child has on the caregiver
and vice versa during communication interaction to aid
language and communication development.

From the scoping review, it became clear that behavioural

variables were measured through observational recording, using
tools (e.g., record sheets) developed particularly for the study
rather than through standardised measures. These measurement
instruments were custom made for each study. This then
influenced the researcher to develop her own recording sheets
and procedural checklists for this study.
Social Social validity is enhanced when the input of stakeholders (and
validity: specifically caregivers who are to be recipients of the training) is
Procedures obtained before and during training - that is, if they have choice
to enhance and voice in the way the programme is designed and
it and administered. From the review, nine studies reported that
measure it parents made choices about and/or gave input on the training
prior to its commencement. These included choices and input on
the materials used (e.g., books), the activities during which
parents applied their newly acquired skills, the vocabulary, the
type of AAC, and the communication functions targeted. In
three studies, focus group discussions were used before
implementing the training program so as to ensure cultural
appropriateness of the content.

Various procedures were implemented to enhance social validity

of the caregiver training programme in this study. The process
involved input from cultural stakeholders to guide the
development of the programme. When the programme was
developed, an expert review process was done with SLPs
practicing in Vhembe to determine the relevance,
appropriateness, and potential effectiveness of the proposed
CgTP. Furthermore, caregivers were asked to choose activities
during which they would implement the intervention strategies.
Lastly, the social validity of the programme was assessed using
a questionnaire that participating caregivers completed.

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6.4 Overview of the CgTP: Materials and content

This section provides an overview of the first iteration of the CgTP as it was
originally conceptualised. The first section will discuss the conceptualisation of the CgTP
and how it was aligned to the Kent-Walsh and McNaughton (2005) instructional protocol.
The CgTP was based (with adaptations) on the instructional protocol by Kent-Walsh and
McNaughton (2005). The original protocol includes eight steps; however, this study will use
six of the eight steps:
(i) Pre-test and commitment to instructional programme - the researcher introduces the
logistics of the training to the participants
(ii) Strategy description - the researcher describes the strategy, its components and steps
required to remember implementation of the strategy.
(iii) Strategy demonstration- the researcher models the use of the targeted strategy as well
as the components and skills needed to carry out the strategy. In the current study, a
video of how other parents have used the strategies will be used.
(iv) Verbal practice of strategy steps – caregivers practice the strategy steps verbally. They
name and describe the steps of the strategy as outlined in the mnemonic.
(v) Advanced practice and feedback (guided practice with feedback) - the participants get
to practice the strategies in a natural environment where the instructor gradually fades
prompts.
(vi) Post-test and commitment to long-term strategy use – the researcher documents and
reviews the participants’ mastery of the strategy and compares the results to baseline.
In this study, intervention probes will be conducted during the guided practice and
feedback step. Once caregivers reach the teaching criteria after 8 sessions, treatment
will cease. After a withdrawal of three weeks, maintenance probes will be conducted.
The way in which the instructional protocol is adapted and taken up in the caregiver
training programme is further outlined in Table 6.3.

6.4.1 Overview of the programme

The programme comprised of various activities during a pre-experimental and an
experimental stage. Table 6.4 shows the initial programme design including the activities
(with indication of scheduling and duration), as well as associated aims, a description of the
activities, materials and equipment.

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Table 6.4
Overview of the Programme: Activities, Aims, Description of Activities, Materials and Equipment

Activities Aims and objectives Description of activities Materials and equipmenta

Pre-experimental stage
Pre-intervention - To ensure caregiver-child dyads Screening and gathering descriptive data - Biographical questionnaire (see
information (CCDs) meet the selection - Administration of the biographical questionnaire (see Appendix E1) and the Likert
gathering and criteria Appendix E1) the Likert scale flash cards (see scale flash cards (see Appendix
screening (3 to 3.5 - To gather biographic data on the Appendix E2) E2)
hrs; 1 -2 sessions) caregiver and to screen the child - Completion of the Communication Matrix (Rowland, 2013) - Communication Matrix (see Appendix F)
- To allow caregivers to choose an based on observations and/or caregiver report (see Appendix - The picture recognition and
everyday activity during which F) representational screening task
they want to implement the - Screening of picture recognition and representational (Appendix G2)
strategies that they will be taught abilities to determine if the child can recognise picture - VFCS (see Appendix H)
during the study communication symbols. A procedural script (see Appendix - MACS and/or mini MACS (see
G1) and recording form (see Appendix G3) will accompany Appendix I2 and I1).
the picture recognition task. The researcher will ask the child - Various materials to elicit fine motor
to point out pictures of items on the PCS board. This task skills (see Appendix J):
will also allow the researcher to complete the VFCS • My body peg puzzle (girl and boy)
(Baranello et al., 2020) to classify the child’s visual function • Fine motor bear puzzle
(see Appendix H). • Linking stars (blocks)
- Screening of the child’s motor abilities using either the or • Zipper, snap button, and
mini MACS (Eliasson et al., 2017) or MACS (Eliasson et.al, button/buttonhole on a pocket
2006) scales (see Appendix I1-I2) depending on the child’s - Video camera
age. The children will be given various materials (as listed to - Cellular phone or voice recorder
the right) to enable the research to observe and classify their
fine motor skills.
Caregiver choice of activity
Caregivers will be asked to indicate an activity they would like
to participate in for the duration of the study wherein videos
will be taken throughout the study.
Commitment to - To ensure caregivers are The researcher will explain the purpose of the pre-intervention - Pre-intervention commitment form (see
training committed to the training and commitment statements. Then, the caregivers will be asked to Appendix K)
implementation of strategies complete and sign the pre-intervention commitment form. The
researcher will provide participants with a copy of their form
as reminder of their commitment.

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Activities Aims and objectives Description of activities Materials and equipmenta

Tablet training - To train caregivers on how to - The researcher will use a script to train caregivers on how to - Tablet training leaflet with a script in
(1 to 2 hrs, 1 day operate the tablets for recording operate the tablet and use the different applications (APPs). English and Tshivenda (see
after screening) and sharing activities - The caregivers will be afforded the opportunity to practice Appendix L1-L2)
recording videos and audio material. Thereafter they will - Video camera,
practice sharing them with the researcher via Google ™drive - Connex 10’1 tablet.
folder.
Experimental stage
Collecting baseline - To collect baseline probes by - The researcher will use a script to instruct caregivers. - Communication board (Activity
probes videotaping the CCDs during Caregivers will be asked to engage with their child in the board) (see Appendix M)
(15-min per interaction with their children chosen activity in a way they would do normally. The - Baseline, intervention and
session) with CCN. caregivers will use the activity board for the chosen activity maintenance probe procedural script
to ensure that baseline and intervention probes were (see Appendix N)
conducted in exactly the same way, but no instruction - Video camera
provided on use of board. The researcher will record 15
minutes of the interaction between the CCD during the
chosen activity.
- A minimum of five baseline probes over five consecutive
days will be collected for the first CCD. The frequency and
scheduling of baselines for the other CCDs will be described
in Section 7.3 of Chapter 7.
Two-day training: Aims A PowerPoint presentation (see Appendix O1 and O2) - Day 1 training presentation (see
Day 1, Session 1a - To create awareness and was prepared on the following topics: Appendix O1-O2)
(1 to 1,5 hrs) impart knowledge regarding Communication - Video camera
communication and AAC to - What is communication? - Communication board (see Appendix
caregivers of children with - Why do we communicate? O3)
CCN. - How do we communicate? - Training booklet (see Appendix P1-
- To teach Strategy 1: Aided - What if one cannot communicate? P2)
language input (Point AAC - Tablets
talking) - What is AAC?
- Who benefits from AAC?
Objectives: - Why should we use AAC (myths and realities
- Caregivers will understand explained)?
what communication is. - Which AAC systems are there?

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Activities Aims and objectives Description of activities Materials and equipmenta

- Caregivers will understand the - How can communication be facilitated using AAC
fundamentals of AAC. strategies with a child with CCN?
- Caregivers will understand and Strategy 1: Point talking
know how aided language - What is ‘point talking’?
input is implemented - How can you use point talking with your child with
CCN in everyday activities?
- The researcher will present the slide show in the participant’s
home, using a laptop. The researcher will put the computer
on a table and display the slide show.
- The caregivers will be given training booklets and stationery
(pen and pencil) to make notes during the presentation.
- The researcher will explain each point and encourage
caregivers to ask questions and contribute at any time.
- A number of reflection activities/interactive activities will
also be part of the training- throughout the presentations,
caregivers will be asked questions regarding their
communication with their children and their children’s
communication skills, such as how their children
communicate, how they think they could improve their
current communication with their child, how they will
implement the strategy taught at home, challenges they
foresee if they were to implement the strategy. The
reflection tasks are usually done after a strategy has been
explained in the presentation.
Two-day training: - To recap content of the - A PowerPoint presentation was prepared on the following - Day 2 training presentation (see
Day 1, Session 1b previous session topics: Appendix Q1-Q2)
(1 to 1,5 hours) - To teach Strategy 2: Revision: What was learnt in Session 1a? - Video camera
Responding to your child Strategy 2: Responding to my child’s - Communication boards (see Appendix
(contingent responding) communication O3)
- What does it mean to respond to your child’s - Training booklet (see Appendix P1-P2)
communication and actions?
- How can you respond to your child with CCN in
everyday activities?
- The presentation will be conducted in a similar way as in
Session 1a. In addition, the caregivers will watch a video

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Activities Aims and objectives Description of activities Materials and equipmenta

and discuss the presence/absence of Strategy 2 as seen in the
video.
- After the presentation, caregivers will be given a homework
activity to complete for the next day. They will be asked to
practice point talking using a communication board provided
and also to practice responding to their child during their
everyday routine. They will be asked to provide the
researcher with feedback on their experience of
implementing the strategies, any challenges they had and
how these challenges could be addressed. They will be
asked to record this feedback using an audio or video
recording on the tablet.
Two-day training: - To recap content of the - Caregivers will be asked to discuss highlights from the - Communication boards (see Appendix
Day 2, Session 2a previous day previous day’s presentation. O3)
(1hr) - Caregivers will be asked if they used any of the - Training booklet (see Appendix P1-
strategies from the previous day P2)
- Caregivers will be asked if there is any specific area that - Presentation slides (day 2) (see
they need the researcher to repeat for clarity. Appendix Q1-Q2)
- Caregivers will be asked these questions from the - Video camera
procedural script for Day 2 of training (see Appendix - Tablets
Q3) - Day 2 training procedural script (see
- Two role play activities will be done to practice the two Appendix Q3)
taught strategies. In the first, the researcher will be a
parent of a child with CCN and the caregiver will
provide this parent with advice. On how to respond
contingently to their child. In the second, the researcher
will be a child with CCN during a mealtime activity. The
caregiver will have to use point talking while interacting
with the ‘child’.
Tw0-day training: - To teach caregivers how A PowerPoint presentation was prepared on the following As stated above
Day 2, Session 2b they can create topics:
(1hr) communication Strategy 3: Providing communication opportunities
opportunities for their - How to offer children opportunities to
child with CCN in daily communicate using 4 strategies:
interaction. - Choice making
- Offering small portions

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Activities Aims and objectives Description of activities Materials and equipmenta

- To teach caregivers the - Offering brief turns
importance of waiting for a child - Making desired items inaccessible.
to communicate during - What to be aware of regarding communication
interaction. opportunities
Waiting
- Importance of waiting for the child to
communicate
Two-day training: - To teach caregivers the - A PowerPoint presentation was prepared on the following As above
Day 2, Session 2c mnemonic O-Mo (Po)-Wa-Re topics:
(30 min) as a strategy to remember Recap: The researcher will remind the caregivers of the
how to implement the strategies that they were taught in the two days, namely
strategies (offering responding to the child; point talking; offering
opportunities for communication opportunities and waiting.
communication, contingent - ‘Putting it all together’: A mnemonic of the strategies
responding and modelling will be presented to the caregivers as a memory aid to help
aided language input) them remember the strategies, however caregivers are
taught the mnemonic (O-Po-Wa-Re) to help them to
discover.
- The presentation will be conducted in a similar way as in
Session 1a.
- After the presentation, caregivers will be given a
homework activity on the strategies to complete and send - Verbal rehearsal of
to the researcher via Google drive on the second day after strategy recording form
training is completed. They will be asked to practice (see Appendix R)
implementing the strategies at home. Verbal rehearsal
homework activity: the caregivers will be expected to
prepare a video of themselves explaining each of the
taught strategies based on the mnemonic, as if they were
teaching another caregiver.
Verbal practice of Caregivers will present the - Caregivers will be asked to share the video with the - Tablet
strategy steps mnemonic O-Po-Wa-Re and share researcher via Google ™Drive after a two-day break after
(two days after the video with the researcher. training. They will be asked to share the video on the
training) morning of the second day.
Intervention probes - To provide caregivers the Probes - Communication boards (see Appendix
- guided practice opportunity to practice the - During each session, the caregiver will conduct the same M)
with feedback implementation of the strategies activity as during baseline, implementing the strategies - Video camera

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Activities Aims and objectives Description of activities Materials and equipmenta

(eight sessions; 1 with their children in a routine of taught with their child. They will be video recorded for 15 - Guided practice and feedback sessions
hour each) their choice and to provide them minutes. No prompting or feedback will be provided procedural script (see Appendix S)
an opportunity to review and before or during recording.
reflect on their implementation. Guided practice/feedback
- To provide caregiver with - After the recording is completed, caregivers will be shown
feedback on their the video of them interacting with child.
implementation. - They will be asked to reflect on their performance and the
- To measure caregivers’ progress interaction. The caregiver will have to reflect on what they
in strategy implementation did, what they could have done more and where they could
improve.
- The researcher will then highlight some of the areas wherein
the caregiver had an opportunity to implement the strategy.
Social validation (1 - To socially validate the - The researcher will read the statements and populate the - Post intervention survey (see
day after last caregiver training survey. The long questions will be transcribed verbatim Appendix T1)
guided practice from the audio record the post intervention evaluation - Likert scale flashcards (see
session) interview with the caregivers. Appendix T2)
- The caregivers will be asked to respond to a statement that - Audio recorder or cellular phone
the researcher will read to them using the 5-point Likert
scale that ranges from strongly agree to strongly disagree.
Furthermore, long open-ended questions will be read to the
caregiver by the researcher.
- The researcher will ask the caregiver open-ended
questions and ask them to provide details. One day
after the last guided practice session, the researcher
conducted a social validation and drafted post
commitment statements with the caregiver.
Post intervention - To draft post intervention - The researcher will facilitate the drafting of post - Post intervention commitment
commitment (1 day commitment statements intervention commitment statements. statement template (see
after last guided with the caregiver - Caregivers will be guided to come up with a vision and Appendix U)
practice session) mission. - Paper
- They will write it down and send photos of the document to - Pen
the researcher or they can do an audio recording for the - Pencil
researcher to transcribe and type it out.
Maintenance - To collect maintenance - Maintenance probes will be collected in the same way as - Video camera
probes (3 weeks probes 3 weeks post baseline probes. At least three probes will be collected. - Communication boards (see
post intervention intervention Appendix M)

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Activities Aims and objectives Description of activities Materials and equipmenta

probes ; 3 sessions - To determine if the caregivers These probes will be collected daily three weeks post
of 15 min each) continued using the strategies intervention
after training ceased.
- To determine the effect of the
training post intervention.
Closure (last day of - To terminate the study with - After collecting maintenance probes on the third day, the - Communication boards (see
maintenance the caregivers and bidding researcher will thank the caregivers for participating in the Appendix O)
probes 30min -1hr) farewell to the participants study. - Tablets
- The researcher will hand over the tablets to the caregiver - Framed commitment statements
officially for them to keep.
- The researcher will hand over the post intervention
statements framed and typed for them to keep.
- The caregivers will be given the other communication
boards (activity boards) that were designed for the study in
a folder for them to use augmented language input with
their children in other activities.
a
Materials referred to here were provisional and the final materials will be in the Appendices

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6.4.2 Development of materials

This section provides a description of materials and equipment that were developed
for the pre-experimental and experimental stages of the study in order to facilitate pre-
training information gathering, screening and pre-training commitment, training and
measurement of the dependent variables, as well as for the assessment of social validity of the
programme. All the materials that were made available to participants in this study were
made available in both Tshivenda and English. Materials were developed in English by the
researcher. The materials were translated from the source language (English) to the target
language (Tshivenda) by a bilingual Tshivenda-English translator. The researcher, who is
bilingual English-Tshivenda, verified the translations. Where there were discrepancies, the
researcher consulted with the translator and the discrepancies were resolved in the meeting in
order to obtain consensus. In this section, all materials that were specifically developed by the
researcher will be described in more detail. Additional materials used in the study is
described in Section 7.6 of Chapter 7.

6.4.2.1 Materials for the pre-experimental stage

(i) Tablet Training Leaflet and Script
A tablet training script and tablet training leaflet in Tshivenda and English (see
Appendix L1-L2) were developed to train the caregivers on how to operate the tablet. The
researcher used the tablet training script to orientate the caregivers on how to use their tablet,
software and applications (apps). The caregivers were given the leaflet to keep. Photographs
of the tablet components and clip art icons for the applications accompanied the text to help
caregivers who needed visual cues to understand the text. The leaflet was designed by the
researcher and it covered the following topics: (1) introduction to the tablet; (2) switching the
tablet on/off; (3) charging the tablet; and (4) describing what each app will be used for. Table
6.5 shows a summary of the topics and a description of the content.

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Table 6.5
Tablet Training Leaflet Content
Topic Description of content
Introduction to the tablet Various components (hardware and apps) of the tablet are outlined in
the leaflet such as:
- Charger cable
- Media cable
- Charging head
- The tablet
- Volume, power and keyboard port
- How to remove the tablet from the case
- Folder with apps and apps
Switching the tablet on/off The on and off buttons were illustrated

Charging the tablet There was information on if the battery percentage is low, the
caregiver can charge the tablet.
Applications (apps) The apps that will be used in the study were outlined together with
their functions. These included Google™ Drive, camera, voice
recorder and gallery. The researcher will go through each app
individually and explain what it will be used for, and how to use it.
- Google drive: It will be used to share voice notes and videos
- Voice recorder: It will be used to record voice notes for the
activities (reflection)
- Camera: It will be used to record videos for the training
activities

(ii) Biographical questionnaire

The biographical questionnaire (see Appendix E1) was drafted to obtain background
information about the child and the caregiver, and to ensure that they met the selection
criteria. The questionnaire was divided into four sections and Table 6.6 describes the different
sections and also provides a theoretical rationale for why each section was included.

Table 6.6
Biographical Questionnaire Description
Sections Description Theoretical Rationale
Section A1- Identifying information of the caregiver This is valuable in compiling background
A A2- Identifying information of the child information of the participants and also to
A3-A4- Information about the child’s fine describe them. Information about motor skills,
and gross motor functioning vision and hearing was gathered to ensure that
A5-A6- Information about the child’s visual the child met the set selection criteria, and was
and hearing status also used to interpret the effects of the
A7- Educational information about the child intervention in a more nuanced manner.
Section Questions about the child’s communication This will be useful in understanding how the
B and communication behaviour. Information child communicates with the caregivers so as
about modes, communication functions and build on their already existing communication
communication partners (Bornman, 2008; skills, as the children are already receiving SLP
Mutthiah, 2015) services in their respective hospitals and are
taught strategies to improve speech-language
and communication outcomes.

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Sections Description Theoretical Rationale

Section Information about activities in which the The researcher was able to identify suitable
C child engages and participates. activities in which the caregiver communicates
with their child. This will help the caregiver to
choose an activity that is suitable for them
(Muttiah et al., 2015).
Section Aims to gather information about the This will provide information on the caregiver’s
D caregiver’s awareness and interests of AAC. knowledge, awareness and interests of AAC.
The researcher will be able identify gaps in
knowledge and awareness of AAC which will
aid in introducing AAC to the caregivers and
promote acceptance thereof (Muttiah, 2015,
Oosthuizen et al., 2018).

Sections B, C and D of the questionnaire were developed by adapting sections of

the questionnaires used in other research studies and PhD theses (Bornman, 2008;
Mutthiah, 2015). The questionnaire was administered as an interview. The researcher filled
it in for the caregivers. The researcher developed flash cards that illustrated the rating
scales that were part of the questionnaire (see Appendix G2).

(iii) Picture Recognition Task and Representational Task

The researcher developed a symbol recognition task (see Appendix G2) in order to
evaluate the child’s ability to recognise PCS symbols. The researcher selected 20 PCS that
were deemed transparent and depicted objects with which children were expected to be
familiar. The choice of objects and PCS was based on the researcher’s experience of being a
Muvenda speech and language therapist and understanding what the child would be familiar
with, the interview results with Vhavenda cultural stakeholders, and knowledge drawn from
research in developing a core vocabulary of Sepedi-speaking children (Mothapo et al., 2021)
as well as research from activity settings of typically-developing children in peri-urban
contexts of South Africa (Balton et al., 2019). The study by Mothapo et.al (2021) on
developing core vocabulary for Sepedi-speaking children was deemed a useful source as the
core vocabulary was for use with preschool aged children, and this study focuses on that age
range. Furthermore, the noun classes in Sepedi and Tshivenda are closely related and it is
difficult to directly translate sentences from English to either of the languages in the same
structure that English follows. Verbs or action words seem to dominate the languages. The
PCS were colour printed on an A4 board within a 5 x 4 grid. Each PCS was accompanied by
the written words in Tshivenda and in English on top of the symbol. The boards were
laminated. A total of 12 of the symbols were designated as test items, while five were

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designated as foils. Three further items were trial items. Table 6.7 shows the trial items, test
items and foils.

Table 6.7
Recognition and Representational level of PCS
Trial and test item Tshivenda word English word
Trial item 1 Sofa Couch
Trial item 2 Tafula Table
Trial item 3 Bodo/pani Pot
Foil Muri Tree
Foil Mmbwa Dog
Foil Vhurotho Bread
Foil Wadiropo Wardrobe
Foil Radiyo Radio
Test item 1 Goloi Car
Test item 2 Bola Ball
Test item 3 Bigiri Cup
Test item 4 Phuleithi/tshigodelo Plate
Test item 5 Lebula Spoon
Test item 6 Vhurukhu Pants
Test item 7 Bulatsho ya mano Toothbrush
Test item 8 Tshisibe Soap
Test item 9 Founu Phone (cell phone)
Test item 10 Bayi/nguvho Blanket
Test item 11 Tshidulo Chair
Test item 12 Tshikipa Shirt

The child was asked to identify a picture that corresponds to a word that the
researcher will name using the carrier phrase “Show me a _______” or “Let’s show (title of
caregiver) the picture of a ______”{“Kha ntsumbedze ________” or “Kha ntsumbedze
_______(title of the caregiver) tshifanyiso tsha ____}. A response would be deemed correct if
the child pointed to the picture that corresponds with the label the researcher would call out.
For the trial items, the child would be asked to point to a picture of an item that the researcher
would call out. After a correct response, the researcher would move on to the next item. If the
child did not point to the correct picture, the researcher would repeat the item and if the child
still did not respond correctly, the researcher would show the child the picture of the item and
move onto the next item. The test items would be presented in three rounds. In the first round,
each item would be presented once, and the researcher would note correct and incorrect
responses. In the second round, all items for which incorrect responses were received in the
first round would again be presented once, after the researcher has asked the child to look

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carefully at the board. The same process would be followed for Round 3, where items that
were incorrect in Round 2 would be presented again.
The researcher would score the child’s responses as either correct or incorrect on a
response form (see Appendix G3). The researcher would score the task by dividing the
number of items correctly identified over the number of total symbols presented, and then
multiply by 100 to get a percentage of correctly identified symbols. In order to be included in
the study the child should correctly identify 75% of the PCS.

(iv) Pre-intervention commitment form

A pre-intervention commitment form (see Appendix K) was developed in order to
motivate the caregivers to participate in the study and commit to behaviour change post
intervention. The form developed also highlighted the activities for the different stages of this
study. The commitment form gave detailed information about all the steps that formed part of
the study (including the durations of all steps) from pre-intervention to maintenance. The
commitment form was provided in both English and Tshivenda. Caregivers were asked to
commit to each step by ticking statements that were applicable to them.

6.4.2.2 Materials for the experimental stage

Various materials were developed for the experimental stage. The materials include
procedural scripts and procedural fidelity checklists for probes, the two-day training and
guided practice with feedback sessions. Furthermore, training slides and training booklets
were developed, as well as the post intervention survey. Table 6.8 shows materials developed
by the researcher for each step of the experimental stage and these will be discussed in
Sections (i) – (vii).
Table 6.8
Activities and Materials Developed for the Experimental Stage
Activity Materials developed
Baseline probes - Communication board (activity board) of the
activity that the caregiver chose.
- Procedural script and checklist for probes
- Timed event recording form
Training Day 1 and 2 - Day 1 and 2 training presentation
- Communication boards
- Training booklet
- Training scripts (Day 1 and 2)
- Procedural fidelity checklist (Day 1 and 2)

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Activity Materials developed

Verbal practice of strategy steps - Response scoring form: Verbal practice and
rehearsal activity
Intervention probes - Communication board (activity board) of the
activity that the caregiver chose.
- Procedural script and checklist for intervention
probes
- Timed event recording form
Guided practice with feedback - Guided practice with feedback: Procedural script
and checklist
Social validation and post - Post intervention survey
intervention commitment - Post intervention commitment form
Maintenance probes - Communication board (activity board) of the
activity that the caregiver chose.
- Procedural script and checklist for probes
- Timed event recording form

(i) Communication boards

Five activity-based communication boards were developed for five different activities
(see Appendix M). These activity boards were used as examples during the two-day training.
The activities included (1) daytime activities (i.e., watching TV, listening to music; listening
to a story or singing), (2) a morning care routine, and (3) dressing and undressing, (4) bath
time, and (5) mealtime activity. Two different boards were developed for dressing and
undressing – one for a boy and one for a girl. These activities were chosen by the researcher
based on the results of the scoping review and the stakeholders’ interviews. From the scoping
review, activities that were reported included reading books, snack time, leisure activities and
unspecified daily activities. During the interviews, stakeholders were asked to outline
activities that Vhavenda children engage in with their caregivers. They reported on child
routines, adult-led activities (chores), physical activities, educational activities and play
activities. The vocabulary chosen for the communication boards was informed by data
gathered from the interviews with cultural stakeholders and Mothapo et al. (2020), as well as
from the scoping review. Furthermore, the researcher selected the vocabulary for the
activities included in this study based on the researcher’s experience as a Muvenda providing
AAC intervention to young children, and in alignment with literature for recommended
practice for choosing vocabulary for young children using AAC (Beukelman & Light, 2020a,
2013; Fallon et al., 2003).
The activity-based boards were made using Boardmaker® 7 editor (Tobii Dynavox,
2021). The boards had Tshivenda and English labels. The cells on the board were 5cmx5cm

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in size. A grid format of 5x4 (rows x columns) was used. The vocabulary on boards was
arranged using the Goossens, Crain and Elder (1992) key to colour code, and categorise word
classes. Pink shading was used for verbs; blue was used for descriptors; green for
prepositions; yellow for nouns; and orange for miscellaneous words such as Wh- questions,
exclamations, negations and pronouns. The boards were printed in colour on an A4 cardboard
and laminated. Table 6.9 shows the proposed vocabulary for the activity boards.

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Table 6.9
Activity Boards Vocabulary
Morning routine Dressing/ undressing Daily play activity Mealtime Bath-time
I / nne (ndi) I / nne (ndi) I / nne (ndi) I / nne (ndi) I / nne (ndi)
Help /thuso (thusa) Help /thuso (thusa) Help /thuso (thusa) Help /thuso (thusa) Help /thuso (thusa)
Finished /fhedza Finished /fhedza Finished /fhedza Finished /fhedza Finished /fhedza
More /habe/hafhu/engedza More /habe/hafhu/engedza More /habe/hafhu/engedza More /habe/hafhu/engedza More /habe/hafhu/engedza
You /Vhone (inwi) You /Vhone (inwi) You /Vhone (inwi) You /Vhone (inwi) Soap/Tshisibe
Toothpaste/ kholugeithi Want /humbela Want /humbela Want /humbela Facecloth/tshitavhula (vasilapi)
Toothbrush /bulatsho ya mano Dressing up /ambara Play /tamba Thank you/ ndo livhuwa Lotion/mapfura
Soap /tshisibe Undressing/ bvula Ball /bola Full/ fura Bath/sambelo (tshigodelo)
Face-cloth/ tshitavhula (vasilpi) Tshikipa / t-shirt Listen /thetshelesa Pray/ rabela Water/madi
Lotion/ mapfura Jersey /dzhesi Sit/ dzula Hot/fhisa In/ ngomu
Eyes/ mato Socks/ masogisi Open mouth / atama Cold/rothola Sit/dzula
Rinse /kulukusha Hat /munwadzi Close /vala Out/ u bva Wash/ tamba
Spit /kha pfe Jeans/bokhathi Throw /posa/ pose Open mouth / atama Oh-oh / yowee
Open /vula Pampers* /leri/phamphasi Story/ folktale/ ngano/ tshitori Close / vala Splash / hasha
Close /vala Long /milapfu/ zwilapfu Radio / radiyo Not nice /a zwi difhi Smear/dodza
Drink /u nwa/inwani Short /mipfufhi/ zwipfufhi Music / dzinyimbo/muzika Hot /fhisa Wipe/ phumula
Face /khofheni Vest /vese Television (TV)/ thivi Cold/ rothola It’s cold/hu kho rothola
Smear /dolani (Specific to girls): (Specific to boys): Food/ zwiliwa Wrap/ putela
Wash /tamba Rokho /dress Cap /gebisi Tired /neta Drink /u nwa/inwani
Cup /bigiri Tshikete /skirt Pants/ vhurukhu Enjoy/nice (phina/zwavhudi) Water/ madi
Underwear/ Underpants / Food/ zwiliwa
panties (phenti) shothopheni
*“Pampers” is a South-Africanism for nappies

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(ii) Materials for collecting probes

The dependent variables related to the child and the caregiver in this study were
measured using observational probes. Probes were collected during baseline, intervention (in
parallel to guided practice sessions) and three weeks post-training (maintenance condition).
A timed event recording form (see Appendix V) was developed to record the DVs for
each caregiver-child dyad. This form was used to record the time and occurrence of target
behaviour by the child or caregiver during the 10-minute interaction. The response recording
form will also be used for inter-observer agreement.
A procedural script and checklist for collecting probes during baseline, intervention
condition and maintenance conditions (see Appendix N) were developed. The procedural
checklist included: greetings, informing the caregiver that a 15-minute video would be taken
of her and her child interacting during the chosen activity, encouraging the caregiver to
ignore the camera, and stipulating that the researcher should remain within view in the
recording to ensure that she did not provide visual or other prompts to the caregiver or child.

(iii) Training Day 1 and 2

The PowerPoint™ 2019 slides (see Appendix O1-O2 and Q2-Q3) for the training
included content based on different topics and videos to illustrate the content. The content for
Day 1 focused on the following concepts: communication, communication development,
AAC and contingent responding; while the content for Day 2 described and explained the
following concepts: creating opportunities for communication, waiting and the mnemonic of
the strategies.
Procedural fidelity checklists were developed for each day of training (see Appendix
O4 and Q3). The checklists were divided into different sections: greetings, explaining of
objectives, discussing the schedule of the day, the researcher introduces the topic, defines the
concepts, check for understanding, afforded the caregiver an opportunity to ask questions and
make comments, shows videos, researcher presented artefacts, facilitates discussions with the
caregiver at the end of each presentation or topic segment and explains the activities for the
day (i.e. reflection tasks, homework activities).

(iv) Response form for scoring verbal rehearsal of strategies

The researcher developed a recording form (see Appendix R) to record the caregivers’
responses during the verbal rehearsal activity. In this activity, the caregivers were expected to

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take a video of themselves explaining the strategies’ mnemonic - O-Po-Wa-Re - to another

caregiver. The response form included the following items: explanation of offering
communication opportunities; examples of offering communication opportunities;
explanation of modelling aided language input (point talking); provision of examples;
explanation of waiting for the child to respond for 6-10 seconds; explanation of responding to
the child's communication behaviour; providing examples of how caregivers can respond to a
child; prompting the child if they do not respond and caregivers responding to the child's
prompted response.
(v) Guided practice with feedback script
The researcher developed a script for the guided practice sessions (see Appendix S).
These activities took place immediately after each intervention probe.
(vi) Post-intervention survey
Social validity is an important aspect in behavioural research because it assesses
social acceptability of interventions and it is important in determining the success of the
intervention (Ogilvie & McCrudden, 2017). A post-intervention survey (see Appendix T1)
was developed for this study in order to evaluate the social validity of the CgTP and to obtain
qualitative feedback on the training programme. The survey was adapted from the Treatment
Acceptability Rating Form - Revised (TARF-R) (Reimers & Wacker, 1992). The original
scale consists of 20 items that are rated on a 7-point Likert scale, related to the constructs
understanding, willingness, severity, affordability, disruption or time, side effects,
effectiveness and reasonableness. The post-intervention survey for this study had 17 closed-
ended questions rated on a five-point Likert scale (1 = strongly disagree; 2 = disagree; 3 = not
sure; 4 = agree; 5 = strongly agree), that were related to the constructs, plus 15 questions that
measured the various constructs understanding, willingness, disruption or time, side effects,
effectiveness and acceptability (in lieu of reasonableness). The description of the constructs is
provided in Table 6.10. The constructs ‘severity’ (i.e., severity of the child’s impairment) and
affordability were relevant for this study, as the severity of the child’s impairment was not
expected to change, and as the intervention did not cost the caregivers anything. The
caregivers were expected to evaluate the CgTP on these constructs. In addition to closed-
ended questions to evaluate social validity, the survey also contained four open-ended
questions to obtain general qualitative feedback on the programme. The caregivers were
expected to explain the reasons for their responses to the open-ended questions. Lastly, one
closed-ended question asked caregivers to rate the overall quality of the training.

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Table 6.10
Post-Intervention Survey Description
Construct Description of the construct Item
number on
the survey
Understanding This evaluates the extent to which the caregivers understand the 1
intervention
Willingness This is the extent to which the family members are prepared to 9-10
alter their routines to encompass and include the intervention.
Effectiveness This evaluates the caregiver’s perceptions of the durability of 2-5; 16
the changes; the likelihood of the intervention to be effectual
and their confidence in the success of the intervention
Reasonableness This evaluates the reasonableness and acceptability of the 6-8
procedures by the caregivers.
Side-effects This is the extent to which caregivers believe there will be 14-15
disadvantages to taking part in the intervention, the level of
discomfort felt by the child and the likelihood of the undesired
side effects.
Affordability This includes the caregiver’s perceptions on the cost and Not included
affordability of the intervention. This aspect was not included in
the study because the caregivers were not expected to pay for
anything related to the study.
Disruption/ This evaluates the caregiver’s perceptions about the amount of 11-13
Time disruption the implementation of the intervention causes to
everyday life and the time required to carry out the intervention
every day.
Severity This aspect evaluates the caregiver’s perceptions of the child’s 17
behavioural difficulties in comparison with their peers.

Caregivers were given a choice to complete the form independently, on hard copy or
electronically. Alternatively, the researcher administered the survey in an interview format;
using flashcards for the Likert scale to assist caregivers to select the ratings (see Appendix
T2).

(vii) Post-intervention commitment statement

A template for a post-intervention commitment statement (see Appendix U) was
developed in order to motivate caregivers to continue using the strategies they were taught
even after training. The template consisted of two headings and their definitions. There was
also an example of how the caregivers could formulate their own post-intervention
commitment statements.

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6.5 Expert review

Expert review focused on consulting experts in the field of study to obtain an
informed opinion about the relevance, appropriateness, and potential effectiveness of the
proposed CgTP for a specific population (Tshivenda speaking caregivers of children with
CCN living in Vhembe district and receiving SLP services in Vhembe). Relevance refers to
the extent to which an intervention is appropriate for the intended population as defined in the
programme. The second dimension is the extent to which the intervention is appropriate for
the intended population, which may be defined by age, culture, or other factors (Fernández-
Gómez et al., 2020; Kassam-Adams et al., 2015). The last aspect is estimated effectiveness.
This refers to the extent to which evidence, theory, and expert judgment would propose that a
specific intervention would successfully change the intended behaviour.
The SLPs practising in the hospitals in Vhembe district of Limpopo participated in an
expert review. The SLPs years of experience working in Vhembe district ranges from 4-25
years. The worked in Vhembe since their community service year and have not left. There
were four females and one male. They all spoke Tshivenda as their home language. The
expert review was conducted electronically. The researcher sent the SLPs emails with
information (see Appendix W1) and the expert review questions attached (see Appendix W2).
The researcher shared the training material with the experts (PowerPoint presentations for the
two-day training in both English and Tshivenda and communication boards) via Google
Drive™. Experts were requested to provide feedback on: (a) the training procedure and (b)
the content of the proposed training programme.

6.5.1 Results of the expert review process

The results of the expert review are summarised in Table 6.11. Only sections that the
experts commented on are reported in the table.

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Table 6.11
Expert Review Results
Aspect of the CgTP Feedback from the experts Changes made
Caregivers will be met individually at their homes - The experts deemed this aspect appropriate, considering Covid-19 No changes were made. The
and children will be screened. Suitable days for regulations. researcher will continue as
training will be agreed upon by the researcher and - The program was reported to be well structured and orderly. planned. The researcher noted the
the caregiver. - Some families are large and there is a likelihood that training will comment about some families
be disrupted being large and the likelihood for
disruptions.
Training will be done individually by the - The experts reported that training in the home was appropriate and No changes were made
researcher at each caregiver’s homes over the beneficial because it allowed caregivers to participate well as they
course of two days. will be in their natural environment.
- E3 reported meeting caregivers individually will allow the
researcher to note and address their specific challenges without
having to generalize proposed solutions or training tips.
Furthermore, home-based sessions will expose the researcher to the
home set-up and the kind of resources the child has, thus allowing
for modification, customization of strategies to fit the individual’s
needs.
The caregiver will be provided with a training - The experts found the idea of a training booklet appropriate as this No changes were made
booklet (see included) will provide the caregivers with a reference to go back to even after
the training has lapsed.
A PowerPoint presentation will be - E4 asked if the materials will be available in Tshivenda although No changes were made
played and the researcher will explain the topics. the Tshivenda version was provided. The rest of the experts
Caregivers will be able to follow in the training approved of the procedure and deemed it appropriate.
booklets. Caregivers will have the opportunity to
ask questions at any time.
Activities will be conducted as indicated on the - E4 suggested that the researcher included training caregivers on The comment from the expert was
PowerPoint and how to make basic communication systems (i.e. communication duly noted, however, this study
the training booklet. boards, vests and etc.) as part of the training. focused on training caregivers on
strategies.
Breaks will be taken as appropriate. The total - The experts highlighted that 3,5 hours was too long, and that the The researcher asked the
training time per day is expected to last 3,5 hours. researcher should show when breaks will be taken. caregivers to decide when they
would like to take breaks at the
beginning of training.

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Aspect of the CgTP Feedback from the experts Changes made

Day 1: Session 1a: Communication - E1 reported that since the caregiver already knows the challenges The suggestion regarding adding
(Slides 5 to 15) her child has regarding communication, the researcher could make questions to the slides was taken
(Booklet: pp. 3 – 7) content with yes/no options to get caregiver to participate during up by the researcher. No other
Please comment on content in general the presentation; so as to improve concentration. changes were made.
Day 1: Session 1a: Point talking - E2 suggested that these two phrases should be added onto the slides
(slides 31-35) "Other people can have negative attitudes toward child and exclude
(Booklet: pp. 13 – 15) child"
Please comment on content in general and “Resulting in low self-esteem"
appropriateness of the strategy.
Day 1: Session 1b: Responding to your child’s - These were suggestions made by E1: The phrase was added onto the
communication. - The researcher should add this onto Slide 39: “They point to” slide. No further changes were
(Slides 36-44) - Maybe give them an example on the different ways of made.
(Booklet: pp16 – 17 communication.
Please comment on content in general and
appropriateness of the strategy.
Day 2: Day 1-Recap - E1 suggested the researcher adds a question to find out if the The researcher planned for
(Slides 5-11) caregivers have questions from the previous day’s session (“I think the recap. Thus, there was
Please comment on content in general. people are more comfortable with asking questions, especially no need to add questions on
when a topic they are not familiar with is introduced”) the slides.
Day 2: Session 1a Offering opportunities for - E1 suggested that the researcher include punishment and reward No changes were made as
communication technique (for example: if the child request for help you give them punishment and reward were not
(Slides 12-24) and if they don't then you don't give them) part of the current study.
(Booklet: pp. 18 – 20)
Please comment on content in general and
appropriateness of the strategy.
Communication boards - dressing / undressing - E2 suggested that clothes worn in summer and winter should be No changes were made because
included on the communication board. caregivers were trained in winter.
Thus, winter clothes were depicted
on the activity boards
Tshivenda booklet - E1 commented on the typos on the Tshivenda version of the The typos were fixed as suggested
programme by the expert.

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Aspect of the CgTP Feedback from the experts Changes made

Reflect on the practicality and usability of the - The programme is practical and user friendly for our population or Not applicable
proposed programme within your context the kind of clients we work with.
- Implementation of this program at an early age will benefit many
caregivers who are frustrated by living with children with CCN.
- This program will enhance the children’s ability to convey their
needs and wants.
- AAC will be easy to master for the caregiver because the proposed
training program will motivate them to use AAC at home.
- The translated version of the training programme is a great idea
because it will give the caregivers more understanding of what the
programme entails in their home language regarding: what is
required from them; what is expected from them and what they
can do to better their communication with their children.
- It is clear, well explained and interesting.
- It gives caregivers and opportunity to learn different mode(s) of
communication to engage with their children and it will give them
less frustrations.
- Children living with a disability will also experience a feeling of
belonging and not feel left out (excluded) due to their special
needs.
- The questions that caregivers might have regarding the
programme are well explained in a way that they will understand,
and they will also understand the child better.
- It addresses common challenges that caregivers encounter when
communicating with their children.
- The practical part is well planned especially because it will be
carried out in the caregivers daily living environment.
- It will then be easier for SLPs to assist caregivers to carry on with
the strategies learned during this study.

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Aspect of the CgTP Feedback from the experts Changes made

Provide any further comments or reflections on The experts suggested the following: Suggestions were noted but were
the proposed training programme - After training, caregivers should meet in a group and reflect on not part of the current study.
their experience of the training; they might have some suggestions
that could also be helpful /useful to others.
- For sustainability purposes, for all the learnt skills and techniques,
there could be a need for an evaluation of the success of the
program after some time interval; maybe on a monthly, quarterly
or bi-yearly basis ensuring the learnt skills continue.
- Looks clear and appropriate for rural caregivers.
- It would be of much help if it may include brief training on how to
make communication boards or apron from any materials
available at home
- Lots of caregivers may benefit a lot from this training even though
they will need further supervision.
- This is an excellent work that will close the gap.

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Overall, experts found most aspects of the CgTP appropriate, relevant and useful. The
experts had a number of suggestions for changes to the CgTP. Some related to additions to
the Power Point slide, as well as corrections of typos, and these suggestions were taken up
and changes were made. Some of the suggestions made, though valuable, were not applicable
to this study, such as teaching caregivers how to make communication boards of their own.
Overall, the experts found the CgTP appropriate and feasible for the target population

6.6 Pilot investigation

A pilot investigation was conducted to test the appropriateness and effectiveness of
the recruitment process, materials proposed for the main investigation, data collection
procedures, research methods and data analysis methods proposed for the investigation
(Thabane et al., 2010). It included checking that the recruitment strategy was effective to
identify suitable caregiver-child dyads (CCDs) who met the selection criteria; that the
selection criteria were appropriate; that data collection procedures were feasible; and that the
research assistant was able to record the dependent variables from the videos. Additionally,
the pilot investigation provided information on the feasibility of using the procedural scripts
and checklists. The reliability of recording the DVs was also assessed. The effectiveness of
the programme was also preliminarily assessed. The pilot investigation was done with one
CCD.

6.6.1 Participants
The pilot CCD consisted of a 28-year old primary caregiver (mother) and her son
aged 6;3 (years; months) diagnosed with an ID. The caregiver has a matric (Grade 12)
qualification; her home language is Tshivenda and she primarily speaks it at home. The child
received speech therapy services once a month at one of the hospitals that gave the researcher
permission to conduct the research. The child functioned at Level III of the Communication
Matrix (Rowland, 2011); Level I of the VFCS (Baranello et al., 2020); and Level 1 of the
MACS. The child’s hearing abilities were within normal limits. The child correctly identified
91,7% of the 12 PCS symbols during the PCS recognition task. The child is an inconsistent
sender and/or receiver of information with their familiar communication partners, thus
functioning at a Level IV of the CFCS (Hidecker et al., 2011). The aims, procedures,
materials, results and recommendations of the pilot investigation are discussed in Table 6.12.

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Child and caregiver were recruited as part of the recruitment for the main
investigation (as described in Chapter 7, Section7.4.2). Seeing that the population for this
investigation was small and specific, all potential CCDs recommended by the therapists at the
participating hospitals were first screened, and then one CCD was selected as the pilot CCD
as they were available and they met the selection criteria.

6.6.2 Aims, materials, procedures, results and recommendations

The aims, materials, procedures, results and recommendations of the pilot
investigation are summarised in Table 6.12. Seeing that recruitment and selection of
participants took place before the pilot investigation (in order to judiciously select a pilot
participant from all possible participants), the recruitment process, screening materials and
procedures as well as the selection process were not part of the pilot investigation.

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Table 6.12
Pilot Aims, Materials/equipment, Procedures, Results and Recommendations
Aim Materials and/ or Procedure Results or Outcomes Recommendations
equipment
To determine if video - Canon Legria HF 806 During the two-day initial caregiver The videos enabled easy recording of The researcher will switch off the
recordings can be video camera training, the researcher took videos of procedural fidelity of the two-day camera sounds for the main
successfully used to rate - Canon IXUS 185 the training with the caregivers using training. A 95% adherence to proposed investigation. The Canon IXUS 185
procedural fidelity as digital camera the Canon Legria HF806 video camera. procedures was recorded for Day 1 and digital camera will be switched on
well as record DVs. - Ring light docking The procedural fidelity of the training 100% for Day 2. without the child seeing as it has great
- Laptop was scored based on playback of the The child did not like the Canon IXUS sound quality and doesn’t require
- Procedural fidelity videos by an independent rater. 185 digital camera because it has a lighting. It will be docked on a tripod
checklists (baseline, During baseline, intervention and retracting lens; he was scared of it facing the caregiver and the Canon
training, guided guided practice and maintenance regardless of where it was placed. The Legria will be docked on the ring light
feedback/intervention probes, the researcher docked the researcher eliminated it for this facing the child for the main
and maintenance) Canon IXUS 185 on the ring light caregiver-child dyad. The researcher investigation.
facing the caregiver. On a tripod stand, took videos with the Canon Legria HF
the researcher docked the Canon Legria 806 video camera and the Huawei Caregivers will be advised to put the
HF 806 video camera facing the child. Nova T5 cell phone. communication boards in clear view of
After recording, the researcher The child and the caregiver were sitting the camera even when they have to
removed the micro SD cards and load facing each other and the pick the boards up in an activity. The
videos on the laptop to view. The communication boards were visible caregivers will also be asked to speak
researcher and the research assistant when the caregiver was pointing, audibly during the activities.
used the videos to record the dependent though in some instances the caregiver
variables. The research assistant also put the board closer to her chest, and
used the videos to rate the procedural only her hand movements showed that
fidelity of the probes. she was pointing to the pictures.
The caregiver would sometimes speak
softly in some videos, though she was
audible. The research assistant would
have to go back on the video to
ascertain what was said and sometimes
ask the researcher if he did not
understand what was said. Initially, it
was difficult, however, with practice,
he was able to record and analyse the
DVs.

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Aim Materials and/ or Procedure Results or Outcomes Recommendations

equipment
To determine the - Device Training The caregiver was trained on how to The device leaflet was well understood Training will happen in the same way
suitability of the leaflet use their Connex 10’1 tablet for basic by the caregiver. However, the pictures in which it was conducted for the pilot
procedure and content of - Connex 10,1’ tablet sharing of audio and video clips, as that were on the pilot participant’s participant with the main investigation
device training for the - Canon IXUS 185 well as using Apps like Google™ meet leaflet were general icons that represent participants. The researcher will use
caregiver digital camera and Google™ drive. She was provided the actual tablet’s icons. Furthermore, pictures of the actual icons that are on
with a leaflet that shows the basic the caregiver enjoyed the session on the tablet for the tablet leaflet for the
functions of the tablet for ease of how to operate the tablet as she was main investigation.
reference. practically sharing different files.
To determine the - Power point The caregiver was given a training The researcher found the script for The researcher will follow the same
suitability of the presentations with booklet and a communication board. each day of training easy to follow. procedure as that of the pilot
materials, activities and embedded videos as The researcher trained the caregiver by The caregiver responded well to the participant for the main investigation.
procedures used during well as a mealtime presenting the PowerPoint on the training. The caregiver asked
the two-day training communication board computer. The laptop was put on a questions, she participated in the The researcher will print the training
for one of the table in their home. discussions and demonstrations tasks. booklet on A4 pages and then put it a
activities during The researcher followed a script to The caregiver gave input during the file presentation folder.
training. train the caregiver on Day 1 and Day 2; discussion activities; she reflected back
the sessions were video-recorded. on some of the general information
- Training booklet An independent rater completed the presented on communication and AAC
- Training procedural procedural checklist based on the video with reference to her son. She tried
fidelity checklist recordings to determine if all demonstrating some of the role play
- Canon Legria HF806 procedures were followed according to activities for augmented language
video camera the Day 1 and Day 2 training checklist. input. She asked for fewer breaks on
- Computer for video Day 1 and 2.
playback She was keen on doing the homework
activities. She found that using Google
drive to share her recordings was a tall
order, so she decided to download
WhatsAppTM for her to share the
homework activities with the
researcher. She was engaged, showed
interest and asked appropriate
questions. She remembered the
mnemonic for Day 2’s homework,
however, she was asked to explain the
one strategy as she forgot to explain it
though she identified it.

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equipment
A problem with the Tshivenda booklet
was noted as the page numbering and
orientation was incorrect due to a
printing problem.

To determine the - Procedural checklist Every day after recording the The caregiver participated fully in the The procedure followed for the guided
appropriateness of the - Canon Legria HF 806 intervention probe, the researcher feedback sessions. The caregiver was practice sessions will remain the same
procedures used during video camera showed the video recording to the able to highlight her strengths and for the main investigation.
guided practice sessions - Computer for video caregiver. The researcher used the weaknesses in each session. The
playback procedural script to ask the caregiver researcher was able to provide the
specific questions about what they did caregiver with feedback on her
during the session. Thereafter, the implementation. The caregiver
researcher provided the caregiver with followed through with the
feedback on their session recommendations and improved in
subsequent sessions.
To determine the - Research assistant The researcher watched the video The research assistant struggled to hear The research assistant and the
reliability and ease of training script recordings of each probe every day and the caregiver’s responses in some of researcher will independently record
recording the dependent - Response form recorded responses and time stamps the segments; however, having responses for the main investigation
variables from the - Canon Legria HF 806 onto the recording sheets based on the replayed the video twice he could make using event time recording using time
videotaped probes . video camera dependent variables defined for this out what she said. There was a 60% stamps. The acceptable difference in
- Computer for video investigation. initial agreement between researcher the time stamps recorded by the
playback The research assistant was trained to and her assistant for recording researcher and research assistant will
record the dependent variables from responses during research assistant be 5sec.
videos that the researcher collected, training. However, training continued
according to the operational definitions until 90 % agreement was reached.
and checklists provided. The research
assistantand researcher watched a 10-
minute video of the baseline session for
the pilot participant. The researcher
and the assistant independently
recorded the variables and compared
the results. The research assistant
training continued until there was a 90-
100% agreement in recording before
the assistant independently recorded
responses of the probes. Agreement

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equipment
between the research assistant and the
researcher was calculated.
To determine the - Response form The researcher and her assistant There were inconsistencies in the way The operational definitions for
appropriateness of the - Canon Legria HF 806 discussed the appropriateness of the the research assistant and the contingent responding and the child
operational definitions video camera operational definitions and amended researcher scored the DV ‘Contingent using augmented output will be
formulated to record the - Computer for video them responding’. It was also noted that the amended for the main investigation
participants responses. playback definition of the DV ‘child using based on the observations from the
augmented output’ was incomplete. pilot investigation.

Contingent responding should include

that the caregiver can comment on the
child’s communicative actions by
asking questions related to the child’s
actions.

The definition of the child DV ‘child

using augmented output’ should
include adapted ways of pointing to the
communication board. For example,
the child can use a pen or the
caregiver’s finger to point to the
communication board
To determine the - Computer The learning criterion set was defined There was a difficulty with the learning The learning criteria set and used in the
effectiveness and - MS Excel 2019 as an increase of 25% or more on all criterion set of a 25% increase on all pilot investigation will be removed for
suitability of the teaching software three caregiver DVs as compared to the the DVs as some were on 0 during the main investigation because some
and learning criteria. highest point during baseline for three baseline, and 25% of 0 cannot be DVs will be at 0. The learning criterion
consecutive probes. A minimum of 5 calculated. will be removed for the main
guided practice sessions with The learning criterion was met for investigation and only a teaching
concomitant probes would be contingent responding and modelling criterion will be used. The criterion is
conducted. Furthermore, a teaching aided language input after three that the intervention condition will be
criterion was also set – intervention sessions. However, for offering stopped after 8 sessions
would cease after eight guided practice communication opportunities the
sessions. The intervention phase would learning criterion was met only on the The researcher will use a minimum of
be introduced to the next CCD when 5th session. It was not possible to cease five baseline probes for all CCD’s in
either of the criteria mentioned above intervention after 5 intervention probes the main investigation to increase
are met. The researcher would plot as per the learning criteria for the pilot chance for stable baseline data.

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equipment
results for each dependant variable for participant as all three caregiver DVs
the caregiver and the child in a showed a decelerating trend by the 5th
different colour on the graph. intervention probe though the learning
criterion was reached by the 5th session.
The intervention probes had to
continue until the 8th session as per the
conditions of the teaching criteria.
To determine Graphic representations The researcher determined level, trend The baseline data was stable when Due to a small number of datapoints,
preliminary effect of the of data (see Appendix and variability of the results, and also using the 80%-25% stability envelope. the researcher decided to use a 80%-
caregiver training X) percentage of non-overlapping data The results of the effect of training on 30% stability envelope (Gast, 2018)
(PND) and Improvement Rate the variables are as follows: due to variability of data with the DVs.
Difference (IRD) in order to report the Contingent responding: an increasing
effect of the intervention on the trend from baseline to intervention was To use NAP and Confidence Intervals
dependant variables. observed. There was relative level to estimate the effect of the
change from baseline to intention, intervention for the main study.
which showed improvement. The IRD
scores showed large effect size from
baseline to intervention (100%). PND
show the intervention to be effective
(100%).
Offering communication
opportunities: There was a slight
increase in trend from baseline to
intervention. The IRD showed a large
effect from baseline to intervention
(75%). PND show the intervention to
be effective (75%).
Modelling aided language input:
showed variability in trend though
there was an increase from baseline to
intervention. The IRD scores showed
large effect size from baseline to
intervention (100%). PND show the
intervention to be effective (100%).
Child communicative turns: showed
an accelerating trend from baseline to

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equipment
intervention. The IRD scores showed
large effect size from baseline to
intervention (87,5%). PND show the
intervention to be effective (87,5%).
Child using augmented output:
showed an accelerating trend from
baseline to intervention. The IRD
scores showed large effect size from
baseline to intervention (75%). PND
show the intervention to be effective
(87,5%).
It can be inferred that caregiver
training was effective for both the
caregiver and child.
To determine if all - Video recordings of The research assistant used the Baseline probes : 100% procedural No changes will be made to the
procedures during all procures during checklists to score adherence to fidelity was reached. procedures for data collection and
training and training and proposed steps during baseline, Training Day 1: 95% procedural training
measurement (probes) measurement intervention and maintenance probes fidelity was reached.
could be executed (probes ) (20% of recordings per condition), as Training Day 2: 100% procedural
reliably - Procedural checklists well as during the initial two-day fidelity was reached.
for probes, intial-two- training and the guided practice Verbal rehearsal of the mnemonic: the
day training, and sessions. caregiver obtained 80% for the activity.
guided practice 80% criteria was set for caregiver to
move to the next step.
Intervention probes: 100% procedural
fidelity was obtained
Guided practice with feedback session:
90% procedural fidelity was obtained.
To evaluate the materials - Post intervention The caregiver participated in a post The caregiver was satisfied with the No changes will be made for social
and process used for survey intervention survey to share her training overall validation
socially validating the - Post intervention experiences of the training regarding Understanding (5-Strongly agree)
training programme survey flashcards the appropriateness of the content, Effectiveness (4- Agree)
logistics and strategies. The caregiver Acceptability in lieu of reasonableness
was asked questions in an interview ( 4-5 rating)
format and the researcher recorded her Willingness (5-strongly agree)
responses on the survey.

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equipment
The caregiver was asked to comment No disruptions to daily activities and
on the appropriateness, acceptability chores were reported. The caregiver
and if the intervention achieved its showed that the strategies align with
goal. The caregiver was asked to make her daily activities.
suggestions for improvements on any Side effects (2-disaree)
aspects of the training. The caregiver mentioned that she
gained knowledge and skills pertaining
to the communication strategies
towards the child’s communication;
and an increase in communication was
reported. The caregiver reported that
the strategies were reasonable and
acceptable by the caregiver.
The caregiver also commended AAC
and the founders. She reported that
AAC is helpful. The caregiver
requested a copy of the board that was
used for screening from the researcher.
To determine the - Writing materials The participant was asked develop her The caregiver wrote down her vision No changes will be made in the
appropriateness of the - Paper own post intervention commitment and mission. She focused on the procedures for developing post
procedures used for - Pictures statement as an activity. The researcher strategies she learned and what she invention commitment statements.
developing post - A4 photo frames provided the caregiver with headings wanted to achieve by using the
intervention commitment - Laminator (vision and mission) and explanations strategies consistently, every day with
statements by caregiver - Laminating sheets of the sections of what to include in a her child. She outlined what she
commitment statement. The caregiver wanted to achieve and expected to
was asked if she would like to write or achieve.
record on audio. The researcher
transcribed verbatim what the caregiver
said. The researcher then printed and
laminated the statements and put them
on an A4 photo frame for the caregiver.

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6.7. Implications for the evaluation phase

The expert review and the pilot investigation resulted in amendments being made to
increase the likelihood that the programme and evaluation material and processes proposed
were appropriate, relevant and useful. Overall, experts found most aspects of the CgTP
appropriate, relevant and useful. Some changes that were made included additions to the
PowerPoint slides.
To summarise the recommendations from the pilot investigation: it was recommended
that the camera functions and placement should be judiciously considered so as to pose
minimal interference in adult-child interactions; the use of adapted pointing would be
acceptable for children who might not want to directly point at pictures during intervention;
the procedure for recording the interaction was changed to event-time recording and the use
of tallying was discontinued. Some of the operational definitions had to be amended for
Phase 3. The pilot revealed the necessity of using a teaching criterion during the main
investigation instead of using both the learning and teaching criteria; furthermore the stability
envelope was also amended due to limited datapoints. The other measures, procedures, and
material were deemed feasible and no amendments were made for Phase 3.

6.8. Summary
The chapter set out the development of the CgTP. It commenced with outlining the
aims of the development phase. Thereafter, the development of the programme was
explained, including the framework that guided the process of development and the sources
of input (theory and findings from Phase 1) that guided content of the programme itself. The
first iteration of the programme was then introduced, including the content and materials.
Following the development, an expert review was carried out electronically with five SLPs
practising in Vhembe. The results were reported, and they showed that the CgTP was
applicable for use and acceptable for the target population. The pilot investigation was then
described, including the participating CCD, the aims, materials, procedures, results and
ensuing recommendations for the main investigation.

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CHAPTER 7
PHASE 3: EVALUATION OF THE CAREGIVER TRAINING PROGRAMME -
METHODOLOGY
7.1 Introduction
This chapter sets out the methodology for the third and final phase of this 3-phase
mixed methods sequential design. This chapter focuses on the methods used for evaluation of
the CgTP. The CgTP was designed and developed based on the data gathered from the
exploratory phase (Phase 1) which comprised of a scoping review (Chapter 4) and Vhavenda
cultural stakeholder interviews (Chapter 5). Expert input and a pilot investigation helped to
further refine the programme during the development phase (Phase 2), as described in
Chapter 6. Figure 7.1 shows the schematic representation of all three phases of the study;
however, the focus of this chapter is on the methodology used during the evaluation phase
(Phase 3).

Figure 7.1
Overview of Methodology

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This chapter commences with setting out the aim and sub-aims of the evaluation
phase. Thereafter, an overview of the stages of the evaluation phase is provided. The design
used is then described, as well as the operational definitions of the dependent variables. A
description of the sampling procedures, recruitment and selection of the participants follows.
Descriptive details of the participants are also provided. The materials used during
recruitment, screening and the experimental stage (training and measurement of DVs) are
described. Furthermore, the data collection procedures are described, including procedures
for the pre-experimental stage (including information gathering and screening, pre-
intervention commitment and tablet training) as well as for the experimental stage (including
baseline, intervention and maintenance probes, the two-day initial training, guide practice and
feedback sessions, as well as post training commitment and social validation). The
procedures used for data analysis are then described. Issues around reliability and validity are
considered, and lastly, ethical considerations are described.

7.2 Aims of Phase 3

7.2.1 Main aim of Phase 3
The main aim of the evaluation phase was to implement and evaluate the
effectiveness of the CgTP, designed to support caregivers of children aged 2-6 years with
CCN who require AAC intervention living in the Vhembe district, in the Limpopo province.

7.2.2 Sub-aims of Phase 3

In order to achieve the main aim of this phase, the following sub-aims were
formulated:
(i) To determine the effect of the caregiver training on the frequency of the caregiver’s
responses contingently to the communication behaviours of the child with CCN
during a 10-minute interaction;
(ii) To determine the effect of the caregiver training on the frequency of the caregiver’s
provision of communication opportunities to their child with CCN during a 10-
minute interaction;
(iii) To determine the effect of the caregiver training on the frequency of the caregiver
modelling aided language input during a 10-minute interaction;
(iv) To determine the effect of the caregiver training on the frequency of the child taking
communicative turns during a 10-minute interaction;

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(v) To determine the effect of the caregiver training on the frequency of the child using
augmented language output during a 10-minute interaction with their caregiver.

7.3 Stages of Phase 3

The stages of this phase are set out in Figure 7.2.

Figure 7.2
Stages of the Evaluation Phase.

Pre-experimental stage Experimental stage

Baseline Intervention Maintenance

Pre-intervention
At least 5 - 2-day training Three
Sampling and information
baseline - Intervention maintenance
recruitment gathering and
probes probes probes collected
36 caregivers screening
collected interspersed with 3 weeks post-
contacted for Consent obtained
guided practice training
possible and 17 child-
caregiver dyads and feedback
participation
screened

Pre-training Social validation

commitment

Tablet
training Post-training
commitment statements

7.4 Design
A concurrent single case multiple probe design was used across three caregiver-child
dyads to evaluate the effect of the caregiver training programme (CgTP) on the frequency
with which caregivers of children with CCN implement three communication strategies in
interaction with their children. The design was also used to determine the concomitant effects
that the CgTP may have on two child communicative behaviours. A SCED multiple probe
design is suitable for evaluating the effect of the intervention that is designed to cause gradual
irreversible changes in behaviour. The design is used when the researcher aims to measure
gradual changes in behaviour over a short period (Ledford, Gast & David, 2018; Tate &
Perdices, 2019). Furthermore, it is also suitable when attempting to show an increase or
decrease in a behaviour that is within the caregiver’s repertoire (Gast & Ledford, 2009;
Ledford & Gast, 2018). This research aims to show an increase in the frequency of certain

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caregiver and child behaviours. The independent variable (IV) in this research is the caregiver
training. Caregivers were taught how to offer their children communication opportunities,
model aided language input, wait five seconds for the child to respond, and respond to their
child’s communication attempts. The caregiver dependent variables (DVs) were: (1)
frequency of offering communication opportunities, (2) frequency of contingently responding
to the child, and (3) frequency of modelling aided language input. Additionally, concomitant
effects of the training on the child were measured by establishing (4) the frequency of
communicative turns taken by the child (5) the frequency with which the child used
augmented output during a 10-minute interaction. Table 7.1 shows the operational definitions
for the DVs related to both caregivers and children.

Table 7.1
Caregiver and Child-Related Dependant Variables: Operational Definitions
Dependent Variables Operational definition
Caregiver-related variables
Frequency of caregiver’s The number of times a caregiver responds contingently to the child’s
responses to child communication attempts or communicative actions within a 10-minute
interaction. This entails any action from the caregiver (verbal or nonverbal)
that indicates that the caregiver has taken note of the child’s communication
act and has either understood it and responds appropriately to it verbally or
non-verbally, or, alternatively, seeks clarification if the caregiver has not
understood it. For example, the caregiver can make a comment in response to
the child’s communicative attempt or communicative actions, ask the child
questions, direct a question to the child for clarity if the caregiver does not
understand what the child wants, or the caregiver can comply with the child’s
request for action or for an item (Broberg et al., 2012; Shire et al., 2016;
Yoder & Warren, 1999).
Frequency with which the The number of times the caregiver offers the child an opportunity to
caregiver offers communicate within a 10-minute interaction using one of the three taught
communication strategies. In this investigation, caregivers will be taught to create
opportunities communication opportunities by using three strategies: (1) choice making:
the caregiver offers the child two options and provides an opportunity for the
child to choose what they would like; (2) offering small portions and brief
turns: the caregiver give the child a small portion of something (e.g., offering
the whole item piece-by-piece to allow the child to request more of that item),
or the caregiver provides a brief turn of an desired activity (e.g., roll a ball to
the child and when the child rolls it back, the caregiver should wait for the
child to request the ball before engaging in another turn allowing the child to
request more); and (3) making desired items inaccessible: the caregiver places
a desired item out of reach but within sight, thus making it inaccessible (e.g.,
by giving the child a transparent container that is tightly closed containing
something that the child wants or holding a desired item out of the child’s
reach), in order to prompt the child to request the item (Campbell & Coletti,
2013; Schlosser et al., 2006; Sigafoos, 1999).
Frequency with which The number of times the caregiver points to the specific graphic symbol on
caregiver models the communication board while at the same time speaking the word or phrase
augmented language input which the symbol represents within a 10-minute interaction (Borgestig et al.,
2017; Dada & Alant, 2009; Dada et al., 2019; Jonsson et al., 2011).

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Child-related variables
Frequency with which the The number of times a child takes a communicative turn during a 10-minute
child takes communicative interaction. In a child with CCN, a communicative turn is taken when the child
turns transmits a message that is directed towards the caregiver, for example when the
child vocalizes in response to the caregiver; or uses eye gaze towards an activity
or object and then to the caregiver; or uses gestures to respond to the caregiver;
or touches or leans towards the caregiver or smiles at the caregiver (Kent-
Walsh et al., 2010; Muttiah et al., 2018; Rosa-Lugo & Kent-Walsh, 2008).

Frequency with which the The number of times a child independently points to a picture on the
child uses augmented output communication board within a 10-minute interaction. This could be after the
caregiver asks a question or when the child initiates communication by pointing
at a symbol on the communication board. The child can point to the picture in
various ways such as pointing using their hands or fingers or using their
caregiver’s hand instead (Romski et al., 2010). For this investigation, only
pointing that is judged to be purposeful and where the child clearly touches the
picture symbol will be regarded as augmented output.

The dependent variables were measured by means of collecting probes under three
different conditions (Ledford & Gast, 2018). These conditions were baseline, intervention
and maintenance. In order to show experimental control and to establish whether a causal
relationship exists between the IV and DV, the intervention was introduced in a staggered
manner across the three CCDs. This means that intervention was introduced to CCD 1 once
stability was seen for the DVs measured during baseline probes while the other two dyads
remain in baseline. Initially, one baseline probe (B1) was collected on the same day for each
of the three dyads. Then CCD 1 baseline probes were collected daily until stability was
reached, where after intervention was introduced. Intervention consisted of two-day training,
a two-day break, followed by eight guided practice sessions. Intervention probes were
collected before every guided practice session. Baseline probes for CCD 2 and CCD 3
continued to be collected every fifth day, and also on the day that the first intervention probe
for CCD 1 was collected. A teaching criterion was set for intervention probes to cease when
eight guided practice sessions had been concluded. The teaching criterion was set to prevent
negative reaction by the participants to repeated measurements (Schlosser, 2003). Three
consecutive baseline probes were collected for CCD 2 once CCD 1 neared the end of their
intervention phase. Once intervention ceased for CCD 1, intervention for CCD 2 commenced,
while baseline probes were still collected for CCD 3 on every fifth day. Once again, three
consecutive baseline probes were collected for CCD 3 once CCD 2 neared the end of
intervention, and intervention for CCD 3 commenced once CCD 2 had completed
intervention.

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7.5 Participants
7.5.1 Sampling
Non-probability purposive sampling was used to select caregivers from the five
hospitals. With purposive sampling, participants were selected based on the characteristics
the possess based on the inclusion criteria. The caregivers who participated in the
investigation were recruited from hospitals in Vhembe district. Typical case sampling methos
was used for this phase of the study as the participants needed to meet a stringent criteria
(Elfil & Negida, 2017; Etikan et al., 2016; Leedy & Ormorod, 2016). Three dyads who met
all the selection criteria, and who were recruited for the main investigation participated in the
evaluation phase (Phase 3). In addition, a pilot investigation was conducted with one dyad
who met the selection criteria proposed for the main investigation, prior to the main
investigation. This pilot dyad did not participate in the main investigation.

7.5.2 Recruitment
Ethics approval to conduct this study was obtained from the Research Ethics
Committee of Humanities, University of Pretoria (see Appendix A), as well as from the
Limpopo Province Department of Health (see Appendix B1) and Vhembe District
Department of Health (see Appendix B2). Permission to conduct research was obtained from
the Head of the Ethics Departments of each of the five hospitals (see Appendix B3) who
service Tshivenda-speaking children and their caregivers.
After obtaining permission from the hospitals, the researcher phoned the chief SLPs at
the hospitals to request their assistance with caregiver recruitment and sent an email with
details (see Appendix Y1). Information letters that included information about the research
and consent forms for caregivers to give consent for SLPs to share their contact details with
the researcher (see Appendix Y2) were emailed to the SLPs. In the same email sent to the
SLPs, the researcher explained the selection criteria set out for this phase of the study. This
was done so that the SLPs would approach caregivers of children with CCN on their
caseloads who met the selection criteria to ask whether they would be interested in
participating in the investigation. When a caregiver showed interest in participating in the
training, the SLPs were asked to either give the caregiver the researcher’s phone number so
they could send a “Please call me” or “Call back” message to the researcher; or to request the
caregiver’s consent to share the caregiver’s telephone number with the researcher. This
consent was documented in writing by the SLPs.

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When caregivers gave consent, the SLPs then shared the caregiver’s number with the
researcher. The researcher phoned the caregivers to give provisional information about the
research, answer any questions, and confirm the caregivers’ interest in taking part. The
researcher also requested the caregivers’ contact details for WhatsApp™ or email, so that she
could send them electronic information letters regarding the research. The researcher sent
each of the caregivers 500MB of data for accessing the information letter.
The SLPs at three of the five hospitals provided the researcher with 38 contact
numbers of caregivers who were willing to participate and who had consented that the SLPs
could share their contact details with the researcher. The SLPs from two hospitals did not
respond to requests for recruitment. The SLP from one of the hospitals resigned after the
emails were sent and no communication was received from the other hospital despite
numerous telephonic attempts. The resident SLP was in meetings and network issues were
reported. The researcher phoned the first 36 caregivers who were recruited from the three
hospitals. Two of the caregivers could not be reached as their numbers remained on voicemail
and they also did not respond to the text messages sent to them, thus leaving the researcher to
recruit from 34 potential participants. The information letters with a consent form attached to
it were sent to the 34 caregivers via WhatsAppTM. Caregivers who showed interest in
participating in the study gave verbal consent after they read the letters. The researcher
phoned them to schedule an appointment for screening. Only 17 caregivers showed interest to
take part in the research. On the day of the screening, the researcher indicated to the
caregivers that only caregivers of children who meet the criteria will be phoned for data
collection scheduling and also those who do not meet the criteria will be informed.

7.5.3 Selection criteria

Table 7.2 describes the selection criteria, justification for the criteria, and
measurement used in order to ensure that both dyad partners (caregivers and children) met
the criteria.

Table 7.2
Selection Criteria for Caregivers
Criterion Justification Measure
They must be the A caregiver is a parent or someone other than the parent who Biographical
caregiver of the child offers care to a child (Children’s Act, 2005, S.3.18). Caregivers questionnaire
aged 2-6 years with CCN of children with CCN would typically take the child for therapy (Appendix E1)
and know the child better than anyone. They also would typically

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Criterion Justification Measure

spend a significant amount of time with the child with CCN and
therefore be able to implement intervention in daily routines since
they interact with the child in these daily routines. This research
targets caregivers of pre-school aged children with CCN who are
communicating intentionally.
Caregivers should live in If there are lockdown restrictions at the time when intervention Biographical
an area where there is starts, then the researcher will have to use a tele-practice model to questionnaire
internet coverage intervene and train caregivers. (Appendix E1)
Caregivers should have Caregivers will be expected to read the material given to them. Biographical
literacy skills in According to Aitchison and Rule (2005), some countries in questionnaire
Tshivenda or English at a SADC consider an adult to have basic literacy when they have (Appendix E1)
minimum level of Grade reached a grade level equal to Grade 4, however in South Africa a
7 Grade 7 level is assumed as basic literacy level (Aitcheson &
Rule, 2005).
Caregivers should be Only caregivers who consent to be video recorded will be Consent form.
willing to be video included in this investigation. Video sessions of caregiver-child (Appendix Y2)
recorded for the repeated interaction need to be recorded for this investigation from
measures throughout the baseline to post intervention conditions.
investigation
Caregivers should be 18 Anyone who is 18 years or older does not require a parent or Biographical
years or older legal guardian to consent on their behalf. They are allowed to questionnaire
legally give consent in South Africa. (Appendix E1)
Caregivers must This investigation is conducted in the Vhembe district in Biographical
primarily speak Limpopo and the programme is being developed to train questionnaire
Tshivenda to their child Vhavenda caregivers. Vhavenda caregivers are the target (Appendix E1)
population for this investigation.

Table 7.3 describes the selection criteria, justification for the criteria, and
measurement used in order to ensure that the children meet the criteria.
Table 7.3
Selection Criteria for the Children
Criteria Justification Measure
The child must have CCN which The investigation aims to train caregivers of Biographical
implies limited speech (i.e. not children with CCN to use aided language input in questionnaire (Appendix
more than 30 intelligible words). conjunction with naturalistic intervention strategies. E1)
Children with limited speech speak less than 30
intelligible words (Dowden, 1997).
The child must be aged 2-6 years This investigation targets caregivers of pre-school Biographical
old aged children with CCN. questionnaire
(Appendix E1)
The child must be receiving SLP The child should be currently receiving SLP Biographical
services in any of the five hospitals services in any of the hospitals in Vhembe as this is questionnaire (Appendix
in Vhembe that provided ethics the target population for this investigation. E1)
approval
Child must be at a Level III (pre- Pre-symbolic communication comprises of Communication Matrix
symbolic level) or higher according communication through motor and vocal (Rowland, 2011)
to the Communication Matrix behaviours according to the Communication Matrix (Appendix F)
(Rowland, 2011) (Rowland, 2011). Children should demonstrate an
intention to communicate for them to be included
in the investigation so as to move them to a
symbolic form of communication.

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Criteria Justification Measure

Child must function at a Level I-III The child must have adequate visual skills Visual functioning
of the Visual Functioning (corrected or not corrected) for them to be able to classification scale
Classification Scale (VFCS) identify pictures on the communication board. (VFCS) (Baranello et al.,
(Baranello et al., 2020) 2020).
(Appendix H)

Child must correctly point out at The children should have adequate representational Picture recognition and
least nine PCS symbols on a skills to recognise PCS. They should also have the representational task
communication board containing 20 visual and motor skills to point to 12 of 20 symbols (Appendix G2)
transparent symbols in a 5 X 4 grid in a 5 X 4 grid on an A4 landscape orientation
in response to a verbal mand board.
(“Show me the …”). The researcher
will request children to point out 12
of the 20 symbols, and children
need to correctly point out at least
75% of these symbols (9/12
symbols).
Child must have functional hearing Aided language input strategy uses augmentation of Biographical
(with or without correction) to hear spoken language with AAC symbols. The children questionnaire (Appendix
the caregivers speak to them during need to hear what the caregivers are saying while E1)
interactions. they point to make an association of the speech
stimuli and the visual symbol.

Child must have adequate motor Children functioning at a Level I-III of the MACS Motor Ability
skills to select PCS. They must be (Eliasson et.al, 2006) or the Mini MACS will be classification system
at a Level I-III of the Motor Ability included in this investigation because they will be (MACS) (Eliasson et.al,
Classification System (MACS) or expected to use direct selection to select the 2006) or the Mini MACS
mini MACS (Eliasson et.al, 2006). symbols. They will be expected to point using their (Eliasson et al., 2017).
finger or hand or caregiver’s hand or a pen or (Appendix I1 and I2)
pencil or straw.

7.5.4 Screening procedures

The researcher provided the caregivers with hard copies of the consent forms for them
to read and sign. Thereafter the research and the caregiver went through the biographic
questionnaire. The researcher read the biographic questionnaire and filled in the answers. The
caregivers were given flashcards that depicted the Likert scale options for them to choose
their options while the researcher recorded the responses on the questionnaire.
The researcher administered the PCS screening task to the child. This was followed
by the fine motor activities and filling in the Communication matrix. The screening sessions
were video-recorded so that the researcher could go through the recording to ensure nothing
was missed and recording on the forms was accurate.
7.5.5 Screening and selection of participants
A total of 34 caregivers were eligible for screening, however, after the telephone calls
that were done by the researcher, 17 caregivers consented to screening . Seventeen caregivers
provided written consent on the hard copy of the consent form for themselves and their
children to participate in the research on the day of screening, though they were sent PDF

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information letters via WhatsApp™. The researcher met each dyad at their home and
screening procedures (see Section 7.5.4) were carried out. Table 7.4 shows the results of the
screening (dyads that met and did not meet certain criteria).

Table 7.4
Caregivers and Children Meeting/Not Meeting the Criteria
Criterion Met the Did not meet
criteria the criteria
Caregiver Criteria
They must be the caregiver of the child aged 2-6 years with CCN 17
Caregivers should live in an area where there is access internet coverage 17
Caregivers should have literacy skills in Tshivenda or English at a minimum 17
level of Grade 7
Caregivers should be willing to be videotaped for the repeated measures 17
throughout the study
Caregivers should be 18 years or older 17
Caregivers must primarily speak Tshivenda to their child 16 1
Child Criteria
The child must have limited speech. They must not have more than 30 17
intelligible words.
The child must be aged 2-6 years old 17
The child must be receiving speech therapy services in any of the five hospitals 17
in Vhembe who provided ethics approval
Child must be at a Level III (pre-symbolic level) or higher according to the 7 10
Communication Matrix (Rowland, 2011)
Child must function at a Level I-III of the Visual Functioning Classification 17
Scale (VFCS) (Baranello et al., 2020)
Child must correctly point out at least nine PCS symbols on a communication 8 9
board containing 20 transparent symbols in a 5 X 4 grid in response to a verbal
mand (“Show me the …”). The researcher will request children to point out 12
of the 20symbols, and children need to correctly point out at least 75% of these
symbols (9/12 symbols).
Child must have functional hearing (with or without correction) to hear the 16 1
caregivers speak to them during interactions.
Child must have adequate motor skills to select PCS. They must be at a Level I- 10 7
III of the Motor Ability Classification System (MACS) or mini MACS (Eliasson
et.al, 2006).

One dyad did not meet the criteria because the caregiver did not primarily speak
Tshivenda to the child, mom spoke English and Sepedi, though the child met all the inclusion
criteria. Nine of the 17 dyads could not be included because their children functioned lower
than Level III on the Communication Matrix (Rowland, 2011); one of the children had visual
difficulties; another child was living with uncorrected hearing loss though he met most of the
criterion; eight children achieved less than 75% on the visual representation and PCS
recognition task; and the children’s motor skills were at Level IV-V on the mini-MACS and
MACS scale. From Table 7.4 it is clear that seven dyads met all the selection criteria (based

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on the both caregiver and child meeting the criteria). From the seven dyads that meet the
criteria, one dyad participated in the pilot study, one dyad could not participate as the child
was living with a suspected hearing loss for which they were awaiting management; three
dyads were part of the main study and the other dyad could not participate in the study post
screening as it was harvest season at their farm and the child and granny could not
participate.

7.5.6 Descriptive criteria

Caregivers participating in this research were described according to their age,
gender, relationship to child, home language, educational level, knowledge, awareness of
AAC, communication skills and interests in AAC. Children who participated in this research
were described according to their age, gender, diagnosis, education, motor, auditory and
communication skills.
CCD 1: The caregiver was a 60-year old female, who is the grandmother and primary
caregiver of her granddaughter aged 3;4 (year;month) living with cerebral palsy. The
caregiver spoke Tshivenda to the child; she had a high school education (Grade 10). She
reported that she did not know anything about AAC and was not aware of it. Her
granddaughter attended an early childhood development centre in their community. She could
produce the words mma (mom) and hm (yes), and attended speech therapy at the local clinic
and one of the hospitals (Hospital A). She presented with adequate hearing and she was able
to point to pictures using her hand though she was unable to walk independently. Her
communication skills were at Level III of the Communication Matrix (pre-symbolic stage).
They lived in a village that is almost 40km away from the hospital where they received
rehabilitation services. They lived from in a 3-bedroomed house that had an indoor toilet that
flushed. They obtained water from a tanker weekly and relied on rain water in their tank for
laundry, cleaning and bathing. There were eight people in total living in the home (child,
grandfather, grandmother, child’s older brother and three cousins).
CCD 2: The caregiver was a 38-year old female, who is the mother and primary
caregiver of her son aged 3;2 (year;month) living with spina bifida, hydrocephalus and
epilepsy. The caregiver primarily spoke Tshivenda to the child and she had a matric (Grade
12). She further reported interest in learning and knowing more about AAC. The child did not
attend an early childhood development centre, produced six intelligible words, namely mma
(mom), baba (dad), gugu (granny), jaja (food), nyanya (water bottle), and vivo (cartoon). He

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presented with adequate hearing; and he was able to point to pictures using his hand, though
he was unable to walk independently. He was at Level III of the Communication Matrix (pre-
symbolic stage). They lived in a peri-urban settlement that is almost 10km away from the
hospital where they received rehabilitation services. They lived in a rented backroom
bachelor pad that had a bedroom, kitchenette, bathroom with a toilet that flushed. There were
four people in total living in the home (child, mother, father, child’s elder brother).
CCD 3: The caregiver was a 39-year old female, who is the mother and primary
caregiver of a 6;10 (year;month) old boy who was born prematurely at seven months
gestation and was living with ID and a communication disorder as well as hemiparesis of the
right side. The caregiver primarily spoke Tshivenda and English to the child. She had a
Diploma in Information Technology. The child was attending a school for learners with
severe ID due to the communication disorder despite the mother’s requests to the district
Department of Education to place him at a school where he would learn South African Sign
Language (SASL). The child spoke 10 intelligible words; he received speech therapy services
at one of the hospitals (Hospital B); he presented with adequate hearing; he was able to point
to pictures using his hand; and he walked independently with a limp. He functioned at Level
VI of the Communication Matrix (abstract symbol). They lived in a peri-urban settlement that
is almost 8km away from the hospital where they received rehabilitation services. They lived
in a 5-bedroomed house that had indoor toilets. There were five people in total in the home
(child, mother, father, child’s older brother and the house keeper).

7.6 Materials, instruments, and equipment

7.6.1 Material for Recruitment
There was a hard copy and electronic version of both the information letter and
consent form. The electronic version was sent to caregivers via WhatsApp™. The hard copy
version was then provided to them during the face-to-face meeting when screening was
conducted. The information letter contained a detailed overview of the research. The
information letter and consent form (see Appendix C2-C3) were available in Tshivenda and
English. The information letter had a reply or consent form attached to it. Caregivers were
requested to indicate their willingness to take part in the research by signing the hard copy of
the consent form.

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7.6.2 Instruments, Materials and Equipment for Screening

The instruments that were specifically developed for this investigation were already
described in Sections 6.4.3 of the previous chapter. Only the additional materials that were
not developed by the researcher and were used for screening are described in this section.

7.6.2.1 Communication Matrix

The Communication Matrix (Rowland, 2013) can be used to assess
communication skills of individuals. Any form of communication is accommodated
and can be assessed on the matrix, including communication facilitated via AAC
systems. Furthermore, it evaluates communication behaviours that are similar across
all languages and cultures. The matrix was developed based on the early stages of
communication development in typically-developing individuals. It covers seven
levels that describe the increasingly complex communication behaviours in the initial
stages of development. These levels are: (1) Level I- pre-intentional behaviours; (2)
Level II- intentional behaviours; (3) Level III- unconventional pre-symbolic
communication; (4) Level IV conventional pre-symbolic communication; (5) Level V-
concrete symbols, (6) Level VI- abstract symbols, and (7) Level VII- language based
communication. Plotting a person’s skills on the Communication Matrix takes the
intentionality (or lack of it) as well as the behaviours people use to communicate with
others into consideration. In the online version of the Communication Matrix, the
researcher entered the participants’ demographic data with no identification details,
and answered the questions about the client based on information she obtained during
a recording of the child’s interaction during the screening and also from questions that
she asked the caregivers if she was uncertain. The programme then generated a report
with results, giving details of the child’s current functioning that can be used in goal
setting. The online version allowed for ease of use, availability, accessibility and
collaboration. Although the matrix is available in 12 international languages it has not
been formally translated to Tshivenda or into any of the African languages. The matrix
was validated for sensitivity to change, and was found to be sensitive to changes in
individuals. For example, a study by Rowland and Schweigert (2000) on nonspeaking
children with pervasive developmental disorders showed a mean gain of 13% in scores
from beginning to the end of the school year. Gains in a larger group of 51 children
(including youngsters with different severe and multiple disabilities) showed a mean gain

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of 10% over the same period. The Communication Matrix has been used for children
aged 1-18 years with various syndromes and neurodevelopmental disorders. Test-
retest reliability was established with a sample of 19 children aged between 1 and 18
years and it was found to be 89%. Inter-rater reliability of 90% was also reported
(Rowland, 2012). There are various studies that have used the Communication
Matrix to determine level of communication of various individuals (Quinn &
Rowland, 2017; Rowland, 2011; Rowland & Fried-Oken, 2010; Rowland &
Schweigert, 1989, 2000; Vaughan, 2018).
The Communication Matrix was used to categorise the communication skills of
the children in this investigation because research has shown that it is valid for
various populations with heterogeneous diagnoses. Furthermore, it has been translated
and used with different language groups and is readily available in those languages,
though not in Tshivenda. A study has shown that it profiled the communication skills
of non-verbal pre-linguistic children from different language groups (English and
Spanish online), however there are other translations that have been used across 104
countries in the same way (Rowland & Fried-Oken, 2010). This investigation
recruited caregivers of children who are intentional communicators and the Matrix
caters for intentional communicators.

7.6.2.2 Manual Ability Classification System (MACS and mini MACS)

The Manual Ability Classification system (MACS) (Eliasson et al., 2006)
allows clinicians to classify children with CP according to how they are able to use
their hands to handle objects in daily activities. It describes how a child with CP
handles everyday objects rather than describing hand functioning. The MACS
describes five levels of functioning and can be used for children 4-18years. The Mini
MACS (Eliasson & Krumlinde-Sundholm, 2013) was developed for use with children
aged 1-4 years. The scale has been translated into 27 languages to date, though not in
Tshivenda. It shows the versatility to move beyond language and cultural boundaries.
The MACS’ reliability index was measured by its intra-class correlation coefficient
(ICC) between therapists (0.97), and its ICC comparing parent and therapist ratings
(0.96). These values show good ICC. For the mini MACS, the ICC between two
occupational therapists was excellent at 0.97 (95% CI 0.95–0.98), and the percentage
of agreement between the occupational therapists was good (at 89%).

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The inter-rater reliability (IRR) of the mini MACS was determined by having
a parent and two occupational therapists administering it to each of 64 participants
aged 1 to 4 years (Eliasson et al., 2017). The IRR between parent and Therapists 1
and 2 was 0.90 with CI of 0.84-0.99. The absolute agreement between parent and
therapists was 65% and 69% respectively. The IRR between Therapists 1 and 2 was
0.97 and the absolute agreement was 89%. Additionally, IRR of age difference was
done. For children up to 24 months this was based on 18 participants. It was found to
be between 0.95 and 0.99 between parents and Therapist 1and 2; the absolute
agreement was 78% for the parents and 94% for the therapists (occupational
therapists). For older children, 25 months and above, IRR was between 0.88 and 0.98.
The results also showed moderate reliability between parents and Therapist 1 (60%)
and Therapist 2 (64%) respectively, and a good reliability index between the two
therapists (91%).

7.6.2.3 Visual Function Classification System

The Visual Function classification system (VFCS) (Baranello et al., 2020) was
used in conjunction with a picture recognition and representational skill assessment
activity in order to describe the child’s visual and representational abilities. The VFCS
was developed and validated to classify visual abilities for children with CP in daily
activities according to five levels (Baranello et al., 2020). The levels are described as
follows:
• Level I: Uses visual function easily and successfully in vision-related activities;
• Level II: Uses visual function successfully but needs self-initiated compensatory
strategies;
• Level III: Uses visual function but needs some adaptations;
• Level IV: Uses visual function in very adapted environments but performs just
part of vision-related activities; and
• Level V: Does not use visual function even in very adapted environments.
The process of ensuring reliability of the VFCS involved ratings by 29
professionals, 39 parents, and 160 children living with CP. The VFCS yielded inter-
rater agreement among professionals of 86% at 95% confidence interval levels, with
test–retest reliability of 95%. Parent–professional inter-rater reliability on 39 children
was moderate and weighted j=0.51. To date the VFCS has been translated to 16

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languages, though not into Tshivenda. This shows that the VFCS is adaptable for use
beyond cultural and language boundaries.

7.6.2.4 Toys used for screening

Various educational toys were used during the screening in order to elicit child
behaviour upon which their communication, visual and motor abilities could be classified
using the classification systems described in Sections 7.6.2.1-7.6.2.3. A summary of the
educational toys is provided in Table 7. 5.

Table 7.5
Toys used for Screening
Toy Description
Boy and girl peg puzzles
The puzzles were used to screen motor skills using
the MACS or miniMACS. The peg puzzles have big
pegs that can be managed by younger children 12 -18
months. These pegs can be easily manipulated by
children who present with mild to moderate fine
motor difficulties. The boy puzzle was used with
male children and the girl puzzle with the female
child. The children had to remove the peg pieces and
then put them back. The researcher orientated the
children before they were allowed to put together the
puzzle.
Linking stars
The linking stars were used during the screening as
part of the motor activity. The children were orientated
to how they can put together the blocks and break them
down because the researcher was uncertain if the
children have been exposed to toys like these.

Fine motor skills puzzle board

The original puzzle had a buckle (belt and seat belt),
button, lace, snap, tie and zip piece for children to
practice their fine motor skills. This investigation used
the snap button piece, zipper and the lacing piece,
though the other pieces were available except for the
actual button.

7.6.2.5 Equipment
Table 7.6 lists and describes the equipment that was used during screening.

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Table 7.6
Screening Equipment Description
Equipment Description
Canon Legria HF R806 and Two video cameras were used to collect videos of the interaction
Canon Ixus 185 digital video between the caregiver and the child as a basis for answering the
cameras questions on the Communication Matrix. The researcher used one
camera for this phase. The camera was positioned at an angle that
allowed for the researcher to capture interaction between the caregiver
and the child. The one camera served as standby due to load shedding
and if the other one stopped working due to memory being full.
A ring light A ring light was sometimes used to capture videos during the 10-
minute interaction so as to get clear videos of the interaction between
the caregiver and the child.
Laptop The researcher uploaded videos taken during screening onto a laptop
and used it for viewing these. Participant data obtained from screening
was also summarised in MS Word and MS Excel files. The laptop
was protected with a password that was known only by the researcher.
All the file formats (MS Word, MS Excel based) were encrypted with
a password and stored on this laptop. Relevant files were also shared
with other team members via the drive.

7.6.3 Materials and Equipment for the Experimental Stage: Training and Measurement
Most of the training material was described in Section 6.4.2 in the previous chapter.
However, the tablets and specific applications loaded onto the tablet that caregivers may
have needed to use (in case of training having to take place remotely and sending
homework activities) are briefly described in this chapter.

7.6.3.1 Applications on tablets

The participants were given Connex 10.1” 16 GB tablets to use in the investigation.
The tablets had applications (apps) and software (an internet browser, video recording
application and audio recording application) that helped with data sharing and recording of
videos or audio that were used during this phase of the study. The researcher used her Student
Google Gmail™ email address provided by the University of Pretoria and created three alias
email accounts for each of the dyads. These email accounts were used to set up their tablets
and allowed them access to Google™ Drive.

7.6.3.2 Equipment
The same equipment that was used during screening was also used during training and
evaluation (see Section 7.6.2.5). Table 7.7 lists additional equipment that was used during
training and measurement.

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Table 7.7
Training and Measurement Equipment Description
Equipment Description
Connex 10.1” 16GB Five Android LTE+Wifi tablet with a MicroSD slot, and a 2MP
tablet camera will be procured. Each caregiver received a tablet. The tablets
were loaded with Apps (Google™ Meet and Drive). The tablets
allowed the caregivers to record and share training activities and
homework activities with the researcher.
Canon Legria HF Two video cameras were used to collect videos of the interaction
R806 and Canon Ixus between the caregiver and the child. The researcher used the same
185 digital video camera for all participants during this phase. The camera was
cameras positioned at an angle that allows for the researcher to capture
interaction between the caregiver and the child. The one camera
served as standby due to load shedding and if the other one stopped
working due to memory being full.
A ring light A ring light was sometimes used to capture videos during the 10-
minute interaction so as to get clear videos of the interaction between
the caregiver and the child.
Laptop The researcher uploaded videos onto a laptop and used it to upload
files onto the drive for other members of the research team. The
laptop was protected with a password that is known by the researcher
and only she has access to it. All the other files formats (MS Word,
MS Excel based) will be encrypted with a password and stored on this
laptop.
Wi-Fi dongle The researcher used a ZTE Wifi dongle to share data and transfer data
from the Tablet to the Google drive.

7.7 Procedures
Covid-19 regulations set out by the South African Government, such as maintaining
social distance between the caregiver and the researcher and wearing of masks, and, where
possible, wearing personal protective gear and using sanitizer were observed when face-to-
face training was conducted with the participants. The procedures included: (a) pre-training
information focussed on gathering, screening and commitment to training; followed by tablet
operation training; (b) collecting baseline probes ; (c) two-day training; (d) intervention
probes and guided practice with feedback until teaching criterion has been reached; (e)
conducting a post intervention survey to evaluate social validity and drafting post
intervention commitment statements; and (f) collecting maintenance probes three weeks post
intervention. Scheduling was arranged with caregivers in such a way that it was convenient
for them, taking the constraints of the design into consideration. In general, sessions were
scheduled on weekdays and Saturdays, but not on Sundays.

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7.7.1 Pre-experimental procedures

7.7.1.1 Pre-intervention information gathering and screening
The researcher telephoned the caregivers who had consented to participate in the
investigation individually to arrange a day and time to collect biographical information about
them and their child. Screening of the child’s abilities was conducted, in order to ensure that
children met the selection criteria and also for descriptive purposes. This was done face-to-
face with social distancing and wearing of face masks maintained based on the Covid-19
regulations. The screening tools that were used to screen and classify the children are
described in Section 7.6.2. Table 7.8 shows the order in which the screening tools were
administered.

Table 7.8
Screening Tool Administration and Order
Tool Administration
Biographical questionnaire The researcher asked caregivers questions from the biographical
questionnaire in the form of an interview. The researcher asked the
caregivers questions while completing the hard copy questionnaire.
Communication Matrix The researcher video-recorded parent-child interaction that was to be
(Rowland, 2011) used as a basis for entering data on the online Communication
Matrix. She also posed some of the questions directly to parents,
using a translated version of the Matrix questions (translated from
English into Tshivenda by herself). Using this information, she
completed the Communication Matrix online after the screening.
The researcher populated the online English version based on the
responses provided by the caregiver.
Motor Ability Classification The researcher provided the children with linking stars (blocks), peg
System (MACS) (Eliasson puzzles, and a fine motor puzzle that had a zipping and snap
et.al, 2006) or the Mini MACS buttoning activity. The children were encouraged to use these toys in
(Eliasson et al., 2017) order to observe and to classify their fine motor skills using the tool.
Picture Communication The child was asked to point to pictures on the boards using carrier
Symbol (PCS) Recognition phrases outlined in Section 6.4.3.1
Task
Visual Function Classification The VFCS was completed by the researcher when the child was
System doing the PCS recognition task. The information gathered on the
PCS task will help the researcher complete the VFCS.

Only four CCD dyads who met all the selection criteria were included in the
investigation procedures described in the following sections. One of these CCDs could no
longer participate in the investigation because the caregiver had to work shifts, while the
remaining three participated in the main investigation.

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7.7.1.2 Pre-intervention commitment

The pre-intervention commitment form is described in Chapter 6, Section 6.4.3.1 and
attached in Appendix K. The researcher explained the form to the caregivers. They were then
given the pre-intervention commitment form to fill out independently. For those who required
assistance with writing, the researcher said the statements and waited for the caregivers to
answer.

7.7.1.3 Tablet Training

The researcher conducted face-to-face training with the caregivers on how to use the
tablet and the software included (Google™ Meet and Google™ Drive). Training was guided
by a script that was embedded on the leaflet in English and Tshivenda (see Appendix L1-L2).
Participants were trained on the operation of the tablet that they used for the training
activities and homework. The tablets had folders with the child’s name that housed all the
apps. They were given a leaflet with visuals that corresponded to the icons on the tablet to
support the tablet training (see Appendix L1-L2).

7.7.2 Experimental procedures

21. Baseline probes
Caregivers were asked by the researcher to select a daily routine from the options
given to them (dressing/undressing routine, morning routine, mealtime, gardening bath
time and leisure activity routine) or indicate an activity of their choice. This was done
during the screening period and the caregivers were asked a few days before baseline
probes were collected to ascertain their initial choice. Caregiver 1 chose a morning routine,
Caregiver 2 a mealtime routine and Caregiver 3 a gardening (watering the garden) activity.
They were given the communication board corresponding to the activity they
chose. However, no instructions were provided on the use of the boards. During baseline
probes, caregivers were asked to interact with their child during the chosen routine in the
same way they would interact typically for at least 15 minutes. The interaction was video
recorded. The first 5 minutes were excluded from analysis. The caregiver and child DVs
were recorded for the remaining 10 minutes of video recording.
A minimum of five baseline probes were collected. Baseline probes for the first
session were collected for all three dyads on the same day. Thereafter, daily baseline
probes for CCD 1 continued to be collected on the following days, until stability was

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reached. Each probe was video recorded. The DVs (frequency of caregivers offering
opportunities for communication, contingent responding, modelling aided language
input, frequency of child taking communicative turns and frequency of child’s pointing at
symbols on a communication board) were recorded from the video recording using the
customised event recording form. The number of times each DV occurred for each
baseline probe was plotted on graphs. There were separate graphs for the caregiver and
the child. The DVs were plotted using different colours and shapes for each DV. Visual
analysis was done in order to determine level, trend and variability. Data were accepted
as stable if 80% of datapoints fell within 30% of the stability envelope (80% - 30%) that
was used to determine stability, as per the procedures proposed by Barton et al. (2018).
Once stability was reached, intervention (training) for CCD 1 started, followed by
collection of intervention probes conducted on a daily basis (except Sundays) before
guided practice with feedback sessions. Additional baseline probes for CCD 2 and 3
were intended to be collected on every fifth day, as well as on the day when the first
intervention probe for CCD 1 was collected. Once CCD 1 neared the teaching criterion,
three consecutive baseline probes were collected for CCD 2 before transitioning into the
intervention condition. A baseline probe for CCD 3 was collected on the day that the first
intervention probe for CCD 2 was collected, whereafter baseline probes for CCD 3 were
supposed to be collected in the 5-day rhythm, followed by three consecutive baseline
probes for CCD 3 as CCD 2 neared the teaching criterion. Due to scheduling clashes the
five-day rhythm for CCD 3 was not kept, with some intervals between baseline probes
amounting to more than five days. However, as will be seen from the graph presented in
Chapter 8, baseline probes were collected on both of the days when the first intervention
probe was collected for CCD 1 and CCD 2, respectively, in order to show experimental
control. Three consecutive baseline probes were also collected for CCD 3 prior to
introducing intervention.

7.7.2.2 Intervention
Intervention consisted of initial training taking place over the course of two days,
followed by a two-day break with a homework activity to be submitted on the morning of
the second day of the break. Thereafter, eight intervention probes and eight guided practice
sessions were conducted for each dyad. Intervention probes were always conducted first.
Thereafter, the researcher viewed the recording made for the intervention probe together

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with the caregiver, and encouraged self-reflection on the caregiver’s performance. Feedback
and suggestions were also provided.

22. Initial two-day training

Individual training was conducted for each caregiver. The initial training took place
over two consecutive days in each caregiver’s home. On the first day, two sessions were
conducted (Sessions 1a and 1b). Within these sessions, the caregiver was taught theory on
communication, AAC, contingent responding and modelling aided language input. On the
second day, three sessions were conducted (Sessions 2a-2c). Caregivers were given an
opportunity to recap the previous day’s sessions and thereafter received training on
strategies for creating communication opportunities and introduction to the mnemonic.
More details about the contents of the sessions were provided in Section 6.4 of the previous
chapter, and a detailed script is presented in Appendix O4 and Q3.
Day 1 training session took an average of an hour for two of the caregivers and an
hour and a half for one. Day 2 training lasted for an hour to an hour and a half. This was due
to the fact that caregivers wanted training without comfort breaks. When caregivers decided
on a break, they would take 5 minutes at the most.
Each day upon arrival, the researcher greeted the caregiver and child. Thereafter the
researcher set up the audio and video equipment where each participant designated (e.g.,
Caregiver 1 was in the lounge; Caregiver 2 was in the bedroom open area; and Caregiver 3
started in the kitchen then moved to the vegetable and flower patches); and commenced
with the recording after which she presented the proposed programme for the day. The
caregiver was invited to suggest any changes in scheduling, and a final programme was
agreed upon.
The researcher started the PowerPoint presentations on her laptop and outlined the
objectives of the day. She also informed the caregivers that they could stop the researcher at
any time during the presentation if they required clarification or needed to ask questions.
During Day 1 of the training, the researcher introduced the first topic, defined it, provided
examples, showed videos and carried out activities with the caregivers. Thereafter, the
caregiver and the researcher discussed the topic at hand for 10-15 minutes before moving on
to the next topic once the previous one was exhausted. This cycle was repeated for all the
other topics until the end of Day 1. The researcher then introduced a homework activity as

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well as the reflection task. She then arranged a time to meet with the caregiver the next day;
before bidding the caregiver, farewell and leaving.
For the second day of training (Session 2), the researcher followed all the steps
pertaining to greetings and setting up of equipment. Afterwards, the researcher and the
caregiver recapped on the previous day’s sessions. If the caregiver needed to ask questions
or ask for clarity, they could do this in the first 45 minutes of Day 2. After the recap and
consolidation session, training continued in the same way in which it was done during Day
1. At the end of the training, the researcher explained the two-day break and the homework
activity that the caregivers needed to submit to the researcher. The two-day break was
chosen by the researcher as she wanted the caregiver to internalise the strategies rather than
relying on immediate recall. The caregivers were told that they needed to record a video of
themselves teaching another caregiver the steps that were captured by the mnemonic “O-
Mo-Wa-Re”. They sent this video to the researcher at 8am on the second day after the initial
two-day training. Thereafter, the researcher greeted the participant and left.
During the two-day break, on the second day of the break, each caregiver sent a
video of the homework activity (explaining the mnemonic). The researcher then used the
timed event recording form for the activity (see Appendix V) to score the caregivers’
performance based on the video recording they had sent, so as to determine if the caregivers
could proceed to the intervention probes (guided practice with feedback sessions). The
learning criteria were as follows: The caregivers had to be able to correctly explain at least
eight of the 10 aspects to remember when implementing the O-Mo-Wa-Re sequence. If they
had not reached the 80% criteria, the researcher would have discussed this with them
telephonically. In this discussion, the researcher would have explained the steps that were
incorrectly explained or omitted. Caregivers would then have been asked to re-do the video
and to send it to the researcher by the afternoon of that day. The researcher would then have
scored the videos again. However, all caregivers achieved more than 80% for their
homework activity at first attempt.

7.7.2.2.2 Intervention probes and guided practice sessions

These sessions commenced the day after the video-recording of the homework
activity was received. Sessions were conducted daily, excluding Sundays, for eught
consecutive days. On each day, the intervention probe was collected first. Caregivers were
asked to engage with their child in the same activity that they had chosen for the baseline

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condition. They engaged in the activity with their child for at least 15 minutes. The
interaction was video-recorded. The researcher did not engage in any prompting or
feedback during collection of intervention probes. A script for the intervention probes is
provided in Appendix N.
Guided practice with feedback sessions was provided immediately after the
intervention probe was conducted. The researcher and the caregiver analysed the video of
the session together. This analysis happened in 5-minute segments (i.e., they watched 5
minutes at a time, and then stopped to discuss). The caregiver reflected on what went well
(identified where they implemented each of the DVs), what could improve for the next
session and where they could have used any of the strategies. The researcher added her
observations about what went well and where the caregiver could improve. A script for the
guided practice sessions is provided in Appendix S. Guided practice with feedback was also
audio and/or video-recorded.
The DVs (frequency of caregiver offering opportunities for communication,
contingent responding, modelling aided language input, frequency of child taking turns to
communicate and frequency of child pointing at symbols on a communication board) were
recorded from the intervention probe videos using the customised recording form. The
number of times each DV occurred was plotted on graphs and visual analysis was done to
determine level, trend and variability in the same way as in baseline condition. Furthermore,
visual analysis was done, comparing baseline and intervention.

7.7.2.3 Post intervention commitment

The caregivers were asked to draft post-intervention commitment statements and
this was done at the end of guided practice with feedback sessions. The caregivers were
asked to use a template to create the post intervention commitment statement (see Appendix
U). The post intervention commitment statements were framed for the caregivers and given
to them as a reminder for them to continuously use the strategies. After completing the
commitment statement, the researcher informed the caregiver that she would return to
collect maintenance probes for three sessions after three weeks.

7.7.2.4 Social validation

Social validation is the process of assessing stakeholders’ perspectives regarding the
social value of the goals, methods and outcomes of the intervention (Schlosser, 1999; 2003).

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An interview was conducted with each caregiver, administering the post intervention survey
that was described in Section 6.4.3.2.6. This was done to assess the social validity of the
caregiver training programme; obtain information on the perspectives of the caregivers
regarding the intervention, the intervention components (goals, methods, outcomes), and how
the intervention was carried out. Furthermore, their perspectives were obtained regarding
whether any changes needed to be made to the programme. The constructs measured were
understanding, willingness, severity, disruption or time, side effects, effectiveness and
reasonableness; these were discussed in Section 6.4.3.2.6 and Table 6.10 in detail. The survey
for the caregivers is given in Appendix T1.

7.7.2.5 Maintenance probes

Maintenance probes were collected daily for each dyad three weeks after the last guided
practice session was conducted. This was done in exactly the same way in which baseline
probes were collected. Three maintenance probes were collected for each dyad.

7.8 Data Analysis

7.8.1 Recording of DVs
The researcher recorded the caregiver’s and child’s communicative behaviours on the
timed event recording sheets. The behaviours were recorded according to the operational
definitions of the DVs for the caregiver and the child (see Table 7.1) respectively. The timed
event recording form (see Appendix V) included the timestamp of when the DV was
observed in the video. The DVs were recorded separately for caregivers and children and
were counted to provide a measure of frequency of occurrence. The caregivers’ DVs included
frequency of contingent responses, frequency of offering communication opportunities and
frequency of modelling aided language input, all measured within a 10-minute interaction.
The child DVs were: frequency with which the child takes turns communicating and using
augmented output during a 10-minute interaction. The number of occurrences of caregiver
and child DVs per 10-minute session were counted and depicted on Excel sheets and then
plotted on a graph.

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7.8.2 Data Analysis

Data analysis for this phase of the study included doing a visual inspection (visual
analysis), as well as estimating effect sizes using the non-overlap of all pairs (NAP) metric.
The confidence interval (CI) was calculated to confirm the effect size.

7.8.2.1 Visual Analysis

Visual analysis was done to evaluate changes within conditions and across conditions.
According to Lane and Gast (2013), visual analysis can be carried out within condition and
between conditions. This was done by following the seven steps as suggested by Lane and
Gast (2013) and Vannest and Ninci (2015). Table 7.9 shows the description of the steps for
conducting visual analysis within conditions. Table 7.10 shows the steps for conducting
visual analysis between conditions. Both tables also provide details of how these steps were
executed in this investigation.

Table 7.9
Steps for Within Condition Visual Analysis (Lane & Gast, 2013;2014)
Steps for within condition analysis Application to the current investigation
Step 1: Assign letters to each condition The following letters were assigned:
- Baseline condition (phase) = A
- Intervention condition (phase) = B
- Maintenance condition (phase) = C
Step 2: Count the number of sessions The number of sessions were calculated and reported
for each condition for each condition.
Step 3: Calculate the mean, median, The mean, median and range were calculated. Then
range and stability for each condition the stability and variation were determined. The
stability was calculated based on the 80%-30%
stability envelope in order to determine if the
level of the DVs was stable or variable within
each phase.
Step 4: Calculate the level of change The difference between the highest point and lowest
within each condition. point within conditions A, B and C was identified.
Step 5: Determine the trend The split middle technique as described by Lane and
Gast (2014) was used to determine trend within
conditions.
Step 6: Determine the percentage of The difference between the first and last value within
datapoints with instability for each each condition was calculated.
condition
Step 7: Evaluate the data paths The free hand method was used to determine the data
paths. This was done manually

The steps followed for between condition analysis are outline in Table 7.10.

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Table 7.10
Steps for Between Condition Visual Analysis (Lane & Gast, 2013;2014)
Steps for between condition Applied to the current investigation
analysis
Step 1: Change in trend direction The data trends between adjacent conditions were
between adjacent conditions compared.
Step 2: Change in trend stability The degree of stability (as calculated within a
between conditions condition, as explained in Table 7.9) was compared
across adjacent conditions.
Step 3: Level change between Calculations were done to determine (a) relative, (b)
conditions absolute, (c) median level change. The procedures as
recommended by Lane and Gast (2013; 2014) were
followed.
Step 4: Overlap of data between The NAP was calculated to determine percentage of
conditions non-overlap. The formula is outlined in Section
7.8.3.2.

7.8.2.2 Non-Overlap of all Pairs (NAP)

The NAP calculation was done to estimate the effect of the intervention. This was
calculated for baseline and intervention conditions (Parker & Vannest, 2009). This metric
considers pairwise comparisons of the all the datapoints and it is not affected by variability as
it takes into account all the datapoints. Each datapoint in the baseline condition is compared
to each datapoint in the intervention condition. In the event of a variable that is hoped to be
increased with intervention, a non-overlapping pair will have a baseline condition datapoint
that is lower than the intervention condition datapoint. This is assigned a value of 1. A tied
pair (baseline and intervention datapoints equal in value) is assigned a value of 0.5. An
overlapping pair has a baseline condition datapoint that has a higher value than the
intervention condition datapoint, and is assigned a value of 0. All values of the overlapping
pairs are summed, and divided by the number of pairs to obtain a percentage of non-
overlapping pairs (Parker & Vannest, 2009). The NAP metric was used to estimate the effect
size, as it is not influenced by variability of data and outliers (Pustejovsky, 2018). Datapoints
were variable within the intervention probes for this study.NAP values of 0.85-1.0 suggest
large effects, 0.32-0.84 show medium effects and 0-0.31 show weak effects intervention
(Parker & Vannest, 2009).

7.8.2.3 Confidence interval (CI)

The Confidence Interval (CI) is a measure used to confirm if the effect sizes are true
(Michiels et al., 2017). The 85% CI for NAP was calculated based on the bootstrapping
technique, as recommended by Parker et al. (2009). The bootstrapping technique allows one

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to estimate without assumption for a normal distribution, but by randomly simulating

repeated observations from the actual data obtained. The CIs for NAP were calculated using
the effect size calculator (Single-case effect size calculator (Version 0.6.1) [Web
application]. https://jepusto.shinyapps.io/SCD-effect-sizes) by Pustejovsky et al. (2022).

7.9 Procedural fidelity and reliability of recording dependent variables

Procedural fidelity is the extent to which a procedure is implemented in the way in
which the researcher intended. The researcher sought to increase procedural fidelity in this
investigation by following a procedural script for all aspects of the intervention and
measurement. Scripts were drawn up for baseline, intervention, and maintenance probes (see
Appendix N), as well as for the initial two-day training (see Appendix O4 and Q3).
The procedural fidelity of both the measurement probes as well as the intervention
procedures was determined for each CCD. A proportion of video footage amounting to
40% of the probes conducted during each condition (baseline, intervention and
maintenance) per CCD, 40% of the training time per caregiver per Day 1 and Day 2
training, and 40% of guided practice sessions as implemented during the intervention phase
were randomly selected and viewed by the research assistant who is a post graduate
honours student and a bilingual English-Tshivenda speaker. The research assistant used a
procedural checklist prepared for probes (Appendix N); Day 1 and 2 training (Appendix
O4 and Q3) and for guided practice (Appendix S) to determine the number of procedural
steps that were correctly executed. The percentage of correctly executed steps was
calculated per session observed using the following formula:
𝑛𝑛𝑛𝑛𝑛𝑛𝑛𝑛𝑛𝑛𝑛𝑛 𝑜𝑜𝑜𝑜 𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐 𝑖𝑖𝑖𝑖𝑖𝑖𝑖𝑖𝑖𝑖𝑖𝑖𝑖𝑖𝑖𝑖𝑖𝑖𝑖𝑖 𝑠𝑠𝑠𝑠𝑠𝑠𝑠𝑠𝑠𝑠
𝑡𝑡𝑡𝑡𝑡𝑡𝑡𝑡𝑡𝑡 𝑛𝑛𝑛𝑛𝑛𝑛𝑛𝑛𝑛𝑛𝑛𝑛 𝑜𝑜𝑜𝑜 𝑠𝑠𝑠𝑠𝑠𝑠𝑠𝑠𝑠𝑠
x 100.

To obtain an average percentage agreement per dyad and per phase, the percentage
agreement scores of all the sessions observed for the particular dyad during the particular
phase were summed and divided by the number of sessions. Results are reported in the
following sections.

7.9.1.1 Procedural fidelity of the probes

The probes were subdivided into baseline, intervention and maintenance probes. Table
7.11 depicts percentage of agreement as a measure of procedural fidelity for the probes.

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Table 7.11
Mean Procedural fidelity of the Probes for all Participants and for all Conditions
Condition CCD1 CCD2 CCD3
Baseline probes 90% 89% 80%
Intervention probes 89% 89% 89%
Maintenance probes 100% 89% 88%

There was an agreement of more than 80% between the researcher and the research
assistant. The percentage ranged between 80% and 100% for all the CCDs. This shows that
the researcher followed most of the steps reliably when carrying out the probes.

7.9.1.2 Procedural fidelity of the training and guided practice sessions

Table 7.12 shows the percentage of agreement for both training days and also for the
guided practice and feedback sessions.
Table 7.12
Mean Percentage of Agreement for Training and Guided Practice and Feedback Sessions
Training procedure evaluated CCD1 CCD2 CCD3
Day 1 Training 100% 100% 100%
Day 2 Training 100% 100% 100%
Guided practice with feedback sessions 100% 100% 100%

The percentage agreement of 100% was obtained between the researcher and the
research assistant for all the CCDs. This shows that the researcher followed all training steps
correctly as set out in the checklists.

7.9.2 Reliability of Recording the Dependent Variables

7.9.2.1 Research assistant training
The research assistant was trained to observe and record the variables as they occur
from the video recording of each session, using a time stamp recording system that was
documented on a timed event recording form (see Appendix V for recording template).
Training was done using the video recording of the first baseline probe for the pilot
participant. The research assistant was instructed to record the occurrence of the first variable
with accompanying time stamps based on the last 10 minutes of the video. The researcher
also independently recorded each occurrence of the first variable with time stamps for the
same section of the video. The researcher and research assistant’s recordings were then
compared and behaviour recordings with accompanying time stamps that differed by no more
than five seconds were counted as agreements, while recordings with time stamps that
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differed by more than five seconds or occurrences of the variable that were recorded by one
person but not the other were counted as disagreements. Where there was a percentage of
agreement below 80%, the researcher and the research assistant discussed the differences.
The research assistant and researcher then watched the video again and rescored the variable.
Once a percentage of agreement of 80% and above was reached, the research assistant and
researcher independently recorded the next variable, and the same process was followed.
Therefore, the research assistant had ample opportunities to practice recording the variables
and also had opportunities for discussion to ensure that he understood what was expected
from him.

7.9.2.2. Timed event recording

Timed event recording was used to enable the researcher and research assistant to
determine inter-observer agreement of recording the dependent variables (see Table 7.1 for
operational definitions) from the video recordings. Timed event recording consists of
recording the occurrence of a dependent variable with a time stamp. This has been reported to
be more reliable than other ways of recording variables observed from videos in intervention
studies (Ledford & Gast, 2018; Walter et al., 2019). The researcher recorded all the
dependent variables from the video recordings of all probes using the time event recording
form. A proportion of video footage amounting to at least 20% of the probes conducted
during each condition (baseline, intervention and maintenance) per CCD was randomly
selected for viewing by the research assistant. Using the timed event recording forms
(Appendix V), the research assistant independently recorded all dependent variables together
with a time stamp of occurrence.
When the occurrence of a dependent variable was scored by both research assistant and
researcher with no more than five seconds difference in the time stamp, this was considered
an agreement. If one observer recorded a dependent variable whereas the other did not, or
when there was a difference of more than five seconds in the recorded time stamp between
the two observers, it was considered a disagreement (Ledford & Gast, 2018 p.193). The
percentage of agreement as a measure of inter-observer agreement (IOA) was calculated per
probe using this formula:
𝑛𝑛𝑛𝑛𝑛𝑛𝑛𝑛𝑛𝑛𝑛𝑛 𝑜𝑜𝑜𝑜 𝑎𝑎𝑎𝑎𝑎𝑎𝑎𝑎𝑎𝑎𝑎𝑎𝑎𝑎𝑎𝑎𝑎𝑎𝑎𝑎
𝑛𝑛𝑛𝑛𝑛𝑛𝑛𝑛𝑛𝑛𝑛𝑛 𝑜𝑜𝑜𝑜 𝑎𝑎𝑎𝑎𝑎𝑎𝑎𝑎𝑎𝑎𝑎𝑎𝑎𝑎𝑎𝑎𝑎𝑎𝑎𝑎+𝑛𝑛𝑛𝑛𝑛𝑛𝑛𝑛𝑛𝑛𝑛𝑛 𝑜𝑜𝑜𝑜 𝑑𝑑𝑑𝑑𝑑𝑑𝑑𝑑𝑑𝑑𝑑𝑑𝑑𝑑𝑑𝑑𝑑𝑑𝑑𝑑𝑑𝑑𝑑𝑑𝑑𝑑
x 100.

An IOA of 80% or more is generally deemed acceptable (House et al., 1981; Watkins &
Pacheco, 2000).

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The results are presented per CCD. For CCD1, sessions B1, I3, I5 and M3 were
selected. Table 7.13 shows the IOA for the sessions for each variable.
Table 7.13
IOA for CCD1
Session/Variable B1 I3 I5 M3
Contingent responding 90.8% 76.8% 81% 85.7%
Offering communication opportunities 100% 79.2% 100% 100%
Modelling aided language input 100% 87.5% 100% 83%
Child communicative turns 87.9% 87.4% 81.4% 85%
Child using augmented output 100% 100% 100% 100%

IOA for CDD1 ranged from 76.8% to 100% between the researcher and the research
assistant for recording variables. The low scores of 76.8% and 79.2% were due to more
behaviours recorded by either the research assistant or the researcher while and the other
recorded less. These disagreements were resolved through a consensus meeting between the
researcher and research assistant, as suggested in the literature (Malviya et al., 2021; Vollmer
et al., 2008).
For CCD 2, the IOA was calculated for sessions B4, I4, I6 and M1. Table 7.14 shows
the values of the IOA for CCD2.
Table 7.14
IOA for CCD2
Session/Variable B4 I4 I6 M1
Contingent responding 91.4% 91% 84.9% 85.5%
Offering communication opportunities 100% 87.5% 100% 88.9%
Modelling aided language input 100% 80.8% 80.5% 81.7%
Child communicative turns 91.7% 88.7% 84.5% 88.9%
Child using augmented output 100% 83.3% 81.8% 100%

CCD 2’s IOA per probe ranged between 80.5% and 100% for the various variables,
showing an acceptable level of agreement for the recording of the dependent variables.
For CCD 3, the IOA was calculated for sessions B2, B6, I1, I5 and M2. Table 7.15
shows the values of the IOA for CCD3.
Table 7.15
IOA for CCD3
Session/Variable B2 B6 I1 I5 M2
Contingent responding 79.3% 80.8% 90% 87.7% 95%
Offering communication opportunities 100% 100% 82.4% 100% 100%
Modelling aided language input 100% 100% 100% 93.3% 100%
Child communicative turns 80.1% 81.5% 80.8% 91% 90.3%

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Child using augmented output 100% 100% 100% 85% 100%

The IOA for CCD 3 ranged between 79.3% and 100% for the various variables. For
most probes, an acceptable level of IOA was obtained. However, the agreement on the
recording of contingent responding for B2 was somewhat low with an IOA 79.3%.

7.9.3 Validity
There are several threats to internal and external validity that need to be considered
when employing single-case multiple-probe designs. Various precautions and safeguards
were taken to minimise these.

7.9.3.1 Internal validity

Internal validity was maintained in this investigation because procedures for the
administration of intervention were similar for all the participants. The researcher and
assistant(s) administered all procedures. In order to overcome some threats to internal validity
such as attrition, experimenter bias and repeated testing, certain measures were taken in this
investigation. Attrition was countered by recruiting at least five participants instead of three
participants. However, the other CCDs could not make the intervention due to caregiver’s
work commitments. The researcher used a procedural script for the training so that it
remained the same for all the participants, thus avoiding training drift. All the DVs were
clearly defined and the same definitions were applied when recording the DVs from the
probes used for baseline, intervention and maintenance. The use of scripts and measures for
coding reliability between the researcher and the research assistant and inter-observer
agreement was used to counter experimenter bias for this investigation. A teaching criterion
was set as a safeguard against boredom and reactivity to repeated testing. Videos were taken
for 15 minutes only during interaction so as to reduce reactivity and boredom of the
participants. The researcher collected probes in baseline before providing training. No
prompting or guidance was provided to caregivers during the probe, as participants served as
their own control in SCEDs, making the need to recruit a control group obsolete.
The introduction of intervention to CCD 1 did not change the baseline performance of
CCD 2 and CCD 3 (see graphs in Section 8.2; Figure 8.1 of the next chapter), and therefore,
it is clear that experimental control was maintained. Though the sample was small, as is
typical for SCEDs in most cases, the replication of the intervention across the three dyads at

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three points in time and collecting baseline measures for the other dyads in a regular fashion
counteracted some of the threats to internal validity. As the study employed a multiple
baseline design that was concurrent, the vertical between participant visual analysis (CCD1 in
treatment while CCD2 and 3 are in baseline) lends additional support that the IV is
responsible for change in DV.

7.9.3.2 External validity

External validity refers to the extent to which results can be generalised to other
settings and populations (Ledford & Gast, 2018). Caregivers were trained in their homes for
this investigation. When familiar partners implement intervention in natural contexts, external
validity is increased. Therefore, the primary caregivers of children with CCN were trained to
implement interventions with their children at home. The heterogeneity of the population that
is typical amongst children with CCN does pose a threat to external validity and limit
generalizability. Participants were described in detail; thus, readers will be able to plausibly
apply results to other dyads with similar profiles. However, producing evidence of external
validity is not best achieved when using single case research as it is not the purpose, internal
validity is, however, it was not the purpose of this study.

7.10 Ethical considerations

Ethics comprise of principles that underlie morality that can be applied to research
(Leedy & Ormrod, 2014; McMillan & Schumacher, 2014). The following principles as set
out in the Belmont report Appendix Volume II (1979) guided this investigation:
Informed consent: The participants were provided with information about the research
in both Tshivenda and English. The information letter was sent to them by the SLP via
WhatsAppTM. If they showed an interest in the research, they either contacted the researcher
directly or gave written consent that the SLP was allowed share their contact details with the
researcher. After telephonic contact with the researcher, those that were still interested agreed
to a face-to-face meeting with the researcher. At this meeting, the content of the consent letter
was discussed with the potential participant and they had the opportunity to ask questions,
before they were given an opportunity to consent or withhold consent for themselves and
their child to participate in the research. By explaining the content of the information letter
verbally, any barriers to informed consent that may have resulted from lower literacy skills
were circumvented. The researcher took special care to explain the time requirements of the

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research, ensuring that she clearly outlined the time commitments that caregivers were
expected to make.
Voluntary participation: The right to voluntary participation was set out in the
information letter. The researcher also reminded participants during the explanation of the
contents of the letter that they were entitled to voluntarily participate in this research and that
they were allowed to withdraw from the research at any time, without negative consequences,
or punishment of any sort. They were assured that non-participation would not disadvantage
them in any way. If participants should choose to withdraw, their data would not be used.
Participants were once again reminded of these rights at the beginning of each day of
training. However, no participant withdrew.
Protection from harm and respect for participants: This research did not involve any
invasive procedures and there were no risks of physical harm associated with participation.
However, some unintended form of harm could have been caused as intervention procedures
took up time and required effort from the participants. The researcher periodically assured
caregivers of their right to withdraw. The caregivers’ schedules were respected and sessions
were only scheduled when it was convenient for them.
The right to privacy: The confidentiality of the participants was maintained in this
research as they were provided identification numbers as a form of protecting their identity.
Their names were thus not written on any of the forms; however, the researcher created a
separate file that was password-protected with a register and the names of the participants.
The file was stored in a different folder from the one with the rest of the information
pertaining to this research. The research assistant signed a confidentiality agreement obliging
him to not share any information about the videos viewed for procedural fidelity and
reliability ratings with anyone.

7.11 Summary
This chapter commenced with setting out the aim and sub-aims of the evaluation
phase. An overview of the stages followed during the evaluation phase was provided. The
single-case multiple-probe design that was used was described, as well as the operational
definitions of the dependent variables. The sampling procedures, recruitment and selection of
the participants were described, and descriptive details of participants were given. The
materials used during recruitment, screening, and experimental stage were described.
Furthermore, the data collection procedures were described, including procedures for the pre-

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experimental stage (including information gathering and screening, pre-intervention

commitment and tablet training) as well as for the experimental stage (including baseline,
intervention and maintenance probes, the two-day initial training, guide practice and
feedback sessions, as well as post training commitment and social validation). The
procedures used for data analysis were then described. Issues around reliability and validity
were considered, and lastly, ethical considerations were described

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. CHAPTER 8
PHASE 3: EVALUATION OF THE CAREGIVER TRAINING PROGRAMME –
RESULTS
8.1 Introduction
This chapter reports the results of the third phase of the study (i.e., the evaluation
phase). The main aim of this phase was to implement and evaluate the effectiveness of the
CgTP designed to support caregivers of children aged 2-6 years with CCN who require AAC
intervention and who live in the Vhembe district, in the Limpopo province. The results of the
experiment are reported per caregiver-child dyad (CCD) according to the effects of the
intervention on each variable, namely on the number of times that, during a 10-minute
caregiver-child interaction, (a) the caregiver responded contingently to the communication
attempts of the child with CCN; (b) the caregiver provided communication opportunities to
their child with CCN; (c) the caregiver modelled the use of aided language input; (d) the
child with CCN took communicative turns; and © the child used augmented output. Each of
the five dependent variables are presented in a graph and visually analyzed according to
procedures described by Lane and Gast, (2014) for within and between conditions. This
includes describing trend, level, stability and immediacy of change. Furthermore, means,
medians, ranges, the non-overlap of all pairs (NAP) effect size and the confidence intervals
(CIs) for each variable are reported.

8.2 Overview of results

A visual representation of the dependent variables as recorded for the three CCDs is
presented in Figure 8.1. Experimental control in a single-case multiple-probe design across
participants that is concurrent can be observed if the introduction of intervention to the first
participant (in this case CCD 1) does not change the baseline measures of the remaining
participants.

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Figure 8.1
Visual Representation of the Results

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As can be seen from Figure 8.1, some of the baseline measures for CCD 2 occurred concurrently
with intervention probes for CCD 1. Similarly, other baseline probes for CCD 3 occurred
concurrently with CCD1’s and CCD 2’s intervention probes.
Levels obtained during these baseline probes for CCD 2 and CCD 3 were not obviously
different from those obtained in prior baseline probes. Similarly, baseline probes for CCD 3
occurred concurrently with intervention probes for CCD 2, and once again, the levels obtained
during these baseline probes were not different from the levels obtained before. It can therefore
be concluded that experimental control was maintained during the investigation.

8.3 Caregiver contingent responding

From Figure 8.1 it is clear that all caregivers already responded contingently during
baseline. The mean numbers of contingent responses per 10 minutes of caregiver-child
interaction for the baseline condition for the three caregivers were 36.6 for Caregiver 1, 69.5 for
Caregiver 2 and 22.2 for Caregiver 3. The median numbers of contingent responses were 35 for
Caregiver 1; 71.5 for Caregiver 2 and 18 for Caregiver 3.
Using a 80%-30% criterion for level stability (Ledford & Gast, 2018), baseline levels of
contingent responding were found to be stable for Caregivers 1 and 2, while Caregiver 3 showed
variability with higher levels of responding in Baseline Probes 2, 3 and 4, which then
deteriorated to lower levels in the last three baseline probes before intervention commenced.
The trend for baseline measures was determined by using the split middle technique
(Lane & Gast, 2013) for each caregiver. The trend for baseline showed a deterioration for
Caregiver 1 and 3, while Caregiver 2 showed an improving trend.
All caregivers had a higher mean number of contingent responses during intervention,
with mean numbers rising to 50.8 for Caregiver 1; 78 for Caregiver 2 and 36.5 for Caregiver 3.
The median values were 46 for Caregiver 1; 75 for Caregiver 2 and 35 for Caregiver 3. Median
level change (or relative level change) when comparing median values of baseline to median
values of intervention therefore suggest improvements in all three caregivers – Caregiver 1
improved by 11 median points, Caregiver 2 by 4.5 median points and Caregiver 3 by 17 median
points. The trend for intervention measures was also determined by using the split middle
technique (Lane & Gast, 2013) for each caregiver. The trend for intervention showed a very
slight deterioration for Caregiver 1, while Caregiver 2 and 3 showed improving trends. However,

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it has to be noted that performance was variable and data paths somewhat eratic, so that the split
middle technique is of limited value.
Caregiver 1 showed an immediate level change. She contingently responded 35 times on
the last baseline and 61 times on the first intervention probe. Caregiver 1’s contingent responding
was somewhat variable during intervention, peaking on the last probe. The values were
increasing and decreasing in the first three probes. There was a decline for Probes 4 and 5 and an
increase (accelerating trend) for the last three probes.
Caregiver 2’s contingent responding decreased to below baseline levels in the first
intervention probe, and thereafter increased consistently in the first four intervention probes,
reaching levels above the highest baseline probe for the third and fourth probes. An inconsistent
decrease and increase were seen in the fifth to eighth probe, with a decrease from the fourth to
fifth probe, while an increase was observed from the fifth and sixth probe, and then another
decrease from the sixth to the seventh intervention probe and an increase from the seventh to the
eighth probe.
Caregiver 3’s contingent responding remained at a low level during the first two
intervention probes. A consistent increase was seen from the third to fifth probe, peaking on the
fifth probe. An inconsistent pattern was observed from the fifth to the eight-probe, characterized
by a decrease from the fifth probe to the seventh probe and an increase from the seventh to the
eighth probe.
NAP was chosen as an effect size estimate (Lane & Gast, 2013; Parker & Vannest, 2009;
Scruggs & Mastropieri, 1998) to describe the change in the variable when comparing baseline
and intervention phases. NAP was chosen as it is not influenced by variability of data and
outliers (Pustejovsky, 2018). Furthermore, to ascertain the precision of the effect size, confidence
intervals (CIs) of 85% were calculated for NAP. The 85% confidence intervals are accepted and
used in single case designs where the data is sparse (Michiels et al., 2017; Parker & Vannest,
2009). The values are given in Table 8.1.

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Table 8.1
Contingent Responding: NAP Values, CIs, and Their Interpretation
Participant NAP
Value and CIs Interpretation
Caregiver 1 0,89 [0,66 -0,97] Strong effect
Caregiver 2 0,61 [0.39 -0.80] Medium effect
Caregiver 3 0,73 [0.51- 0.87] Medium effect

The normative ranges for the NAP are as follows (Parker & Vannest, 2009 p.364): NAP
values between 0-0.31 show weak effects; values between 0.32-0.84 show medium effects; and
values between 0.85-1.0 show large or strong effects. Based on NAP values, the intervention
showed a strong effect for Caregiver 1, while the effect sizes for Caregiver 2 and 3 showed
medium effects of the intervention. It can be concluded that the intervention had medium to large
effects for contingent responding. This can be assured by the CIs obtained for the NAP values.
The CI for Caregiver 1 was narrow, with a difference of 0.31. For Caregivers 1 and 2, the CIs
were somewhat wider. However, the lower boundaries of all CIs were still within the medium
effect range.
From Figure 8.1, it is clear that levels of contingent responding were not maintained post
intervention. The mean number of contingent responses deteriorated to 24.7 for Caregiver 1; 61
for Caregiver 2, and 29.7 for Caregiver 3. The median values also decreased when compared to
the intervention phase. The median values were 24.5 for Caregiver 1, 55 for Caregiver 2 and 27
for Caregiver 3. All caregivers showed an immediate drop in level when comparing the number
of contingent responses during the last intervention probe to those obtained during the first
maintenance probe. Levels remained low for all caregivers, with some variability seen for
Caregiver 2.
The trend for the maintenance condition was also determined by using the split middle
technique (Lane & Gast, 2013) for each caregiver. The trend for the maintenance condition
showed deterioration for all three caregivers for contingent responding. Child 2 had been
hospitalized with an infection, while the doctors also needed to adjust his medication for seizures
just prior to commencing with maintenance probes. Child 1 was recovering from flu during
maintenance probes, as there was a rise in flu cases in their area in November and December
2021. This possibly affected the caregivers’ responses during maintenance.

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8.4 Caregiver offering communication opportunities

Figure 8.1 shows that during baseline, none of the caregivers used the specific strategies
that together were defined as offering communication opportunities to their children. These
strategies included offering choices, offering brief turns and small portions, as well as putting a
desired item out of the child’s reach but not out of the child’s sight. The mean number of
communication opportunities offered for baseline was therefore 0 for all three caregivers.
During the intervention probes, the mean number of times caregivers used the strategies
to offer communication opportunities were 1.8 for Caregiver 1; 12.4 for Caregiver 2 and 1.5 for
Caregiver 3. Caregivers also showed an increase in the median values for intervention which
were 3 for Caregiver 1; 6.5 for Caregiver 2 and 1 for Caregiver 3.
None of the caregivers showed an immediate level change when comparing the last
baseline probe to the first intervention probe. Some of the datapoints showed performance
returning to or remaining at zero during some of the intervention probes for the three caregivers
(Intervention Probes 4, 5 and 7 for Caregiver 1; Intervention Probe 3 for Caregiver 2; as well as
Intervention Probes 2 and 3 for Caregiver 3). In general, gains remained somewhat modest, with
Caregivers 1 and 3 never exceeding a level of five opportunities offered during intervention
probes. Caregiver 2 increased her number of opportunities to a greater extent, with the number of
opportunities peaking at a level of 61 during the seventh intervention probe. However, this
performance seemed to be somewhat of an outlier, with performance during the remaining
probes ranging from zero to 16. During the last intervention probes, all of the caregivers showed
levels above zero and therefore an improved level as compared to baseline, with Caregiver 1
offering three opportunities, Caregiver 2 offering seven opportunities, and Caregiver 3 offering
two opportunities.
When the split-middle technique was used to determine trend for within intervention
condition, Caregiver 1 showed a deteriorating trend, while both Caregivers 2 and 3 showed an
improving trend.
The NAP values are displayed in Table 8.2 with their interpretations.

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Table 8.2
Offering Communication Opportunities: NAP Values, CIs and Their Interpretation
Participant NAP
Value and CIs Interpretation
Caregiver 1 0.75 [0.50, 0.89] Medium effect
Caregiver 2 0.88 [0.66, 0.96] Strong effect
Caregiver 3 0.81 [0.58, 0.93] Medium effect

There is evidence that the intervention had a positive effect on the number of times the
three caregivers used the strategies they had been trained on to offer communication
opportunities to their children. This can be seen in the results presented in Table 8.7 based on the
NAP values. However, the effect is not strong for Caregivers 1 and 3 (i.e., medium effect size),
however, strong effects were seen for Caregiver 2. The CIs obtained for Caregiver 1 were [0.50,
0.89], for Caregiver 2 [0.66, 0.96] and for Caregiver 3 [0.58, 0.93]. The CI ranges obtained for
the NAP values ranged varied from 0.30 to 0.39, thus showing they are narrow. It can be
concluded that the NAP values were precise with 85% confidence.
From Figure 8.1, it is clear that levels of use of the strategies to offer communication
opportunities were not well-maintained post intervention. Compared to intervention, the mean
number of times strategies were used deteriorated to 5.7 for Caregiver 2 and to 0 for Caregiver 3.
However, there was an increase in mean for Caregiver 1 (M =2). The split middle technique
showed that the trend for the maintenance condition was deteriorating for Caregiver 2 and Null
for Caregivers 1 and 3.
Caregivers 1 and 3 showed an immediate drop in level when comparing the number of
opportunities provided during the last intervention probe (3 for Caregiver 1 and 2 for Caregiver
3) to those obtained during the first maintenance probe (2 for Caregiver 1 and 0 for Caregiver 3)
while Caregiver 2 showed an immediate increase in level from 7 to 9. The levels, however,
remained low for all caregivers.

8.4.1 Caregiver modelling aided language input

From Figure 8.1, it is clear that none of the caregivers modelled aided language input for
their children before they were trained, as baseline measures were at zero for all caregivers. All
caregivers had a higher mean number of instances of modelling aided language input during

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intervention, with numbers rising to 28.5 for Caregiver 1; 52.9 for Caregiver 2 and 17.8 for
Caregiver 3. The median values were 28 for Caregiver 1; 58 for Caregiver 2 and 16 for Caregiver
3. All caregivers displayed an immediate level change when comparing the last baseline probe
(being zero for all the caregivers) to the first intervention probe, with Caregiver 1’s modelling
increasing to 26 times, Caregiver 2’s modelling to 29 times, and Caregiver 3’s modelling to 16
times. The relative level change shows an improving trend from baseline to intervention.
Caregiver 1’s modelling behaviour was somewhat inconsistent during the first five
intervention probes, showing a decrease from the first to the second probe, then a peak during the
third probe and returning to baseline levels during the fourth and fifth probe. Modelling again
peaked during the sixth intervention probe, and levels were also relatively high in the seventh
and eight intervention probes, although a decreasing trend was seen in the last two probes.
Caregiver 2’s behaviour was also inconsistent in the first five intervention probes, showing an
decrease from the first to the second probe, then an increase in the third probe, and a slight
decrease again in the fourth probe. An increasing trend was seen over Intervention Probes 5 and
6, a drastic decrease was observed in Probe 7 and a significant increase in Probe 8. Caregiver 3
showed a somewhat variable pattern during intervention. Frequencies observed varied between
10 and 27, without a clear trend. The highest frequency was obtained during the sixth probe, and
thereafter performance declined during the seventh and eighth probes.
Non-overlap of all pairs (NAP) were calculated as estimations of effect size (Lane &
Gast, 2013; Parker & Vannest, 2009) in comparing baseline and intervention phases. The results
are summarized in Table 8.3. The suggested interpretations for these values are depicted in Table
8.3.
Table 8.3
Modelling Aided Language Input: NAP Values with Their Interpretation
Participant NAP
Value and Cis Interpretation
Caregiver 1 0.88 [0.64, 0.96] Strong effect
Caregiver 2 1.0 [1.00, 1.00] Strong effect
Caregiver 3 1.0 [1.00, 1.00] Strong effect

Intervention for modelling aided language input was effective for all the caregivers from
baseline to intervention and is evident based on the NAP and this can be supported by the visual

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analysis. The CIs obtained for all the caregivers on NAP values were narrow, indicating that
there is great precision of the effect of the intervention (Parker et al., 2009).
From Figure 8.1, it is clear that levels of modelling aided language input deteriorated
during maintenance probes, specifically for Caregivers 1 and 3, although Caregiver 3’s levels
increased from 10 in the last intervention probe to 13 in the first maintenance probe. The mean
number of modelling aided language input deteriorated to 14 for Caregiver 1, and 5.7 for
Caregiver 3. Caregiver 2 showed a slightly better performance, with a mean number of
modelling aided language input of 50.3 during maintenance, which is well above the baseline
performance of zero and only slightly below the average obtained during intervention (M =
52.9).
However, her performance in the first maintenance probe dropped to a level of 83 as
compared to a level of 113 during the last intervention probe, and performance further
deteriorated in the last two maintenance probes to levels of 33 and 35 respectively. When using
the split-middle technique to determine trend, all three caregivers showed a deteriorating trend
for this variable during maintenance

8.5 Child communicative turns

From Figure 8.1, it is clear that all children already took communicative turns during
baseline. The mean number of child communicative turns for baseline was 44.4 for Child 1; 84.7
for Child 2 and 25.2 for Child 3. The medians were 50 for Child 1; 28.5 for Child 2 and 25 for
Child 3. Using an 80%-30% criterion for level stability (Ledford & Gast, 2018), baseline levels
of child communicative turns were found to be stable for all the children. Child 1 and Child 3
showed deteriorating trends while Child 2 showed a slightly increasing trend.
All children had higher mean values for child communicative turns during intervention,
with averages rising to 81.5 for Child 1, 112.4 for Child 2 and 52.1 for Child 3. The median
values for the number of times the child took communicative turns during intervention was 92
for Child 1; 112 for Child 2 and 46.5 for Child 3. Both median and relative level of change
between baseline and intervention showed improvements.
Using the split middle technique to estimate trend, all three children showed accelerating
trends for child communicative turns during intervention. Child 1 showed an immediate level
change from 40 in the last baseline probe to 99 in the first intervention probe. Some variable

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performance was then seen in the first four probes, but then steadily increased performance in
Probes 5-7, with only a slight decrease again in Probe 8. Child 2 showed an initial decrease in
level (95 in last baseline probe to 88 in first intervention probe), while Child 3 showed an
increase in level from 14 to 26 when the last baseline probe was compared to the first
intervention probe. Both Child 2 and Child 3 showed increasing trends in the first four and five
intervention probes respectively, and thereafter performance became slightly variable.
NAP was calculated to estimate effect size (Lane & Gast, 2013; Parker & Vannest, 2009)
in comparing baseline and intervention phases. The results are summarized in Table 8.4. together
with the suggested interpretations for these values.
Table 8.4
Child Communicative Turns: NAP Values, CIs and their Interpretation
Participant NAP
Value and CIs Interpretation
Child 1 0,93 [0.70, 0.98] Strong effect
Child 2 0,92 [0.71, 0.98] Strong effect
Child 3 0,96 [0.79, 0.99] Strong effect

The intervention had a strong effect on the variable child communicative turns for all the
children when comparing baseline to intervention. It can be concluded that the intervention was
effective according to the NAP metric. The CIs obtained were: Child 1 [0.70, 0.98], Child 2
[0.71, 0.98] and Child 3 [0.79, 0.99]. The CIs obtained for the NAP values were relatively
narrow, suggesting that there is 85% confidence in the precision of the effect.
From Figure 8.1, it is clear that levels of child communicative turns achieved during
intervention were not maintained post intervention for Child 1 and 2. Mean number of child
communicative turns deteriorated to 45 for Child 1 and to 83.3 for Child 2. Child 3’s
performance was slightly better maintained, only deteriorating somewhat from an average of
52.1 during intervention to an average of 50.3 during maintenance. All children displayed an
immediate drop in level when comparing the number of child communicative turns during the
last intervention probe to those obtained during the first maintenance probe. All three children
exhibited deteriorating trends for child communicative turns during maintenance.

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8.6 Child using augmented output

From Figure 8.1, it is clear that none of the children pointed to symbols on the
communication boards during baseline and their performance was at zero for all tiers. All
children had a higher mean number during intervention, with numbers rising to a mean of 10.5
for Child 1; 8.3 for Child 2 and 13.4 for Child 3. The median values increased during
intervention to 5 for Child 1; 6.5 for Child 2 and 10.5 for Child 3. All the children showed an
immediate level change when comparing the last baseline probe to the first intervention probe,
with Child 1’s performance rising from 0 to 5, Child 2’s performance from 0 to 3, and Child 3’s
performance rising from 0 to 4. All three children showed variable levels of this behaviour
during intervention, but generally increasing trends according to the split middle technique.
Child 1 and Child 2 showed limited use of the board in the first few sessions, but then an
increase was evident. Child 1’s pointing to the communication board was inconsistent in the first
five intervention probes, varying between 0 and 5. The child’s performance peaked in Probe 6 at
38, and thereafter a decline was seen for Probes 7 and 8. Child 2’s behaviour was also on a low
level for the first three probes, with frequencies varying between 1 and 5. During Probe 4, the
child’s behaviour increased until it peaked in Probes 5 and 6, and then a decline was seen for
Probes 7 and 8. Child 3’s performance was variable during intervention, ranging in frequency
between 4 and 28. From Intervention Probes 4 to 6 and increase was observed, with behaviour
peaking, similar to Child 1 and 2, in the sixth intervention probe, while a decline was seen for
Intervention Probes 7 and 8.
NAP values were calculated as estimations of effect size (Lane & Gast, 2013; Parker &
Vannest, 2009) in comparing baseline and intervention phases. The results are summarized in
Table 8.5.
Table 8.5
Child Using Augmented Output: NAP Values, CIs, and their Interpretation
Participant NAP
Value and CIs Interpretation
Child 1 0,81 [0.57, 0.93] Medium effect
Child 2 1,00 [1.00, 1.00] Strong effect
Child 3 1,00 [1.00, 1.00] Strong effect

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Child 2 and 3’s results showed a strong effect from baseline to intervention, while Child
1’s effect size shows a medium effect according to NAP values. The CIs obtained were narrow
for all three children: Child 1 [0.57, 0.93], Child 2 [1.00, 1.00] and Child 3 [1.00, 1.00].
From Figure 8.1, it is clear that levels of producing augmented output were not maintained
post intervention. Mean number deteriorated to 3.7 for Child 1; 4.3 for Child 2 and 1.7 for Child
3. Child 2 showed an increase from 1 to 9 from the last intervention probe to the first
maintenance probe; Child 1’s datapoints stayed the same and Child 3 showed an immediate drop
in level when comparing the number of times, the child used augmented output during the last
intervention probe to those obtained during the first maintenance probe. Levels deteriorated over
the three maintenance probes for all children, with Child 1 ending on 1, Child 2 on 2 and Child 3
on a level of 0.

8.7 Social validity

A post-intervention survey was used to obtain evidence of social validityof the
intervention with the caregivers. A total of 17 closed-ended Likert scale questions were included,
based on the Treatment Acceptability Rating Form - Revised (TARF-R) (Ogilvie & McCrudden,
2017). The Likert scale was a 5-point scale ranging from strongly disagree (rating of 1) to
strongly agree (rating of 5). There were four open-ended questions that asked caregivers what
they liked, if they wanted to change anything about the programme, and if the programme had
positive and/or negative consequences. Lastly, they were asked to rate their level of satisfaction
from very satisfied to very unsatisfied on a scale of 1 to 5, with a neutral answer (3) if they were
“unsure”. The results of this social validaty are discussed according to the domains measured by
the TARF-R, namely understanding, effectiveness, acceptability, reasonableness, willingness,
disruption/time, side effects and overall satisfaction with training. Table 8.6 shows the summary
of ratings for each of the domains.

Table 8.6
Average Caregiver Ratings for Constructs
Construct Number of questions Average rating obtained Range
Understanding 1 5 5
Effectiveness 6 4.7 4-5
Acceptability in lieu of reasonableness 3 4.8 4-5

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Willingness 2 4.7 4-5

Disruption 2 4.7 4-5
Time 1 4.6 4-5
Side effects 2 4.7a 4-5
Overall satisfaction 1 5 5
a
These items were reverse scored so that a high score indicated a small disruption/time sacrifice, and minimal side
effects.

From Table 8.6 it is evident that the average ratings obtained showed that the CgTP was
socially valid. High ratings were obtained on items related to understanding, effectiveness,
acceptability in lieu of reasonableness, side effects and willingness. This means the caregivers
understood the content and what they had to with their children, that they perceived the
programme to be effective in increasing their own knowledge and skill and also to improve their
children’s communication skills. They also found the programme to be acceptable for them and
their families, and they were willing to share what they had learnt with others. Caregivers saw no
negative consequences and side effects associated with the training and were overall satisfied
with it. All three caregivers indicated that the implementation of the training activities did not
disrupt much of their daily activities as it was embedded in their natural routines. Furthermore,
they reported that the strategies they learned fit easily into their routines.
Regarding the first open-ended question, caregivers reported that they liked various
aspects of the training. Two caregivers reported that they liked the strategies overall, and one
reported she liked offering children choices, teaching the children how to sequence activities
(i.e., what comes after washing your face in a bath-time routine, praying before eating in a
mealtime routine) and also the importance of responding. The caregivers reported that the
training improved their child’s language development (i.e., sentence construction, saying words).
When the caregivers were asked if they wanted to make any changes to the training programme,
they unanimously reported that they liked the programme as it was and would not like to make
any changes.
Caregivers were asked if they could observe or foresee any negative consequences to
using the strategies they learned with their child. In their responses, they reported that overall,
they expected no negative consequences as the programme had helped with facilitating
communication with their children, given that every child has a right to communicate.
Furthermore, one of the caregivers highlighted that child with disabilities, including
communication disabilities, have the right to learn like their peers without disabilities and that

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the charts (communication boards) offered their children the opportunity to learn. Another
caregiver reported that the strategies provided their children “a right way” of communicating.
In conclusion, caregivers were asked if using the strategies taught had positive
consequences. Their responses showed that they observed positive outcomes in various aspects
of communication and interaction. They reported less frustration during communication with
their children because they responded to the children’s communication attempts; they reported
“open” communication with their children (i.e., communicating freely) and those children were
beginning to articulate words more intelligibly. They also reported that the programme facilitated
their children’s understanding of everyday items (i.e., what a cup is and what it is used for), and
that it increased their own awareness of how to communicate with children with CCN.
Furthermore, the strategies brought about understanding between their children and other
communication partners, especially when the children pointed to the boards. Caregivers also
reported that they set aside time during the day to orientate their children to the communication
board and the symbols and trying to understand what their children wanted.
All three caregivers indicated that they were ‘very satisfied’ with the training in response
to the 5-point Likert scale question probing overall satisfaction. Table 8.7 shows some of the
words and word approximations that children had started producing (according to parent reports)
after being exposed to the training programme. Word approximations are spelled phonetically as
they were spoken.

Table 8.7
Parent Report of Words and Word Approximations Spoken by Children Post Intervention
Child ID Words
Child 1 Pfa (spit),
ee (yes)
ii (used when you are giving someone something)
Child 2 Vhevhe/vhea (put)
Vuye/Vule (researcher’s name)
Nama (meat)
Yesh (yes)
Child 3 Baby
Nne (I)
Futhi (More)
Thuso (Help)
Bumba (fat one)
Puck/ prick (he calls the thorn plant)
Bruce/Bruno (Dog’s name)

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8.8 Summary
This chapter described the results of the effects of the CgTP on the five variables that
were outlined for this phase of the study. Furthermore, the results pertaining to the rating of the
social validity of the programme were presented.
The CgTP was shown to have medium to strong effects on the five variables (including
caregiver and child variables). Strong effects were seen for modelling aided language input for
all three caregivers and child communicative turns for all three children. Medium effects were
seen for Caregivers 1 and 3 for the variable offering communication opportunities; Caregivers 2
and 3 for the variable contingent responding; and Child 1 for the variable child using augmented
output. The rest of the caregivers and children showed strong effects for offering communication
opportunities, contingent responding and child using augmented output. It can therefore be
concluded that the training had medium to strong effects for the dependent variables.
The caregiver training was rated positively by caregivers and was shown to have social
validity according to the participants.

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CHAPTER 9
PHASE 3: EVALUATION OF THE CAREGIVER TRAINING PROGRAME -
DISCUSSION
9.1. Introduction
The effects of the CgTP on the variables are discussed in this chapter. The independent
variable was CgTP, and the dependent variables for caregivers were: (a) the frequency of
caregivers contingently responding to their children; (b) the frequency of the caregiver offering
the child communication opportunities; and (c) the frequency of the caregivers modelling aided
language input to their children – all as measured during a 10-minute caregiver-child interaction.
The child concomitant variables were (a) the frequency of the child taking communication turns;
and (b) the frequency of the child using augmented output during a 10-minute interaction. The
effects of the CgTP will be discussed according to the caregiver and child variables and then
compared to other studies that measured the variables. Reasons for the differences and
similarities will be discussed.

9.2. The effects of CgTP on the caregiver variables

The results of the CgTP showed medium to strong effects of the intervention for
contingent responding and caregiver offering communication opportunities for some of the
caregivers; while there were strong effects on modelling aided language input. However, none of
these effects were maintained for any of the variables and for any of the caregivers’ post
intervention.

9.2.1. The effect of the CgTP on caregivers contingently responding to their children in a 10-
minute interaction
The caregivers were contingently responding to their children during baseline (i.e., even
before the intervention began), which means they had this skill prior to training. Caregivers
across cultures respond contingently to their children (Tamis-Lemonda et al., 2014) without
needing training to do so, but this process can be disrupted when children are less
communicative and responsive (Slonims et al. 2006). The fact that caregivers responded
contingently to children before training may have been partially influenced by their attendance of
speech-language therapy with their children prior to the commencement of the investigation.

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However, all three caregivers increased the frequency of responding contingently to their
children during intervention. In light of the important role that contingent responding plays in
children’s communication development, this is to be welcomed. For example, caregivers’
contingent responding has been shown to increase the expressive language of children (Paavola
et al., 2005; Tamis-Lemonda et al., 2001). Thus, the more the caregivers respond, the more
encouraged the children are to communicate. The more children communicate with the
caregivers, the more the caregivers recognise, interpret and respond to the children’s
communication. This therefore sets in motion a virtuous cycle to enhance child communication
development.
The results obtained in this investigation differed somewhat for each caregiver-child
dyad. Caregiver 1’s performance on contingent responding showed that the intervention had a
strong effect and an improvement in this behaviour was seen during intervention. The caregiver
was responding contingently more frequently to the child’s behaviour during intervention.
Medium effects of the intervention were seen for Caregivers 2 and 3. The variability in the
results for the three caregivers may have been due to various reasons. For example, differences
between the caregivers’ responsiveness could possibly be attributed to either child or caregiver
characteristics. Sigafoos et al., (2000) report that caregivers are more responsive when children
tend to display vocal behaviours rather than non-vocal behaviours such as gestures and/ or facial
expressions. Various studies showed that where children display intentional communicative
behaviours, caregivers tend to respond contingently more often than when children are pre-
intentional communicators (Yoder & Warren, 1999). Additionally, when caregivers perceive their
children to have a severe disability, contingent responding will be negatively affected as
caregivers perceive the child not to be able to communicate.
The child’s mode of communication might affect contingent responses from the caregiver
(i.e., when child is intentional in their communication by pointing to something and vocalising, it
is easy for the caregiver to interpret and respond to the child’s communication attempt) (Cress et
al., 2013). The likelihood of caregivers noticing the child’s communication behaviours is higher
when the child uses a more understandable method of expression, whereas a less understandable
method would lead to inconsistencies in recognising the attempt (Deveney et al., 2016).
Although strong effects were seen for Caregiver 1, her child seemed unwell during the
second intervention session and this caused a decrease in the frequency of contingent responding

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(see Figure 8.1). Furthermore, Caregiver 2’s child was ill during their first two sessions, which
could explain why the number of times she contingently responded to her child gradually
increased after the first two sessions. Caregiver 3’s performance on contingent responding
decreased in the last few sessions. This may have been related to the child’s challenging
behaviour. The child exhibited escape behaviour and would move away from the location of the
task where he was supposed to water and the caregiver would have to bring him back to task. As
caregiver contingent responding depends directly on the child’s actions, it is to be expected that
caregivers have more difficulty responding contingently when the child is not responsive or is
unwilling to engage (Cress et al., 2013; Sigafoos et al., 2008).
Previous studies have also shown how training was effective in increasing the frequency
of contingent responding in parents. Broberg et al. (2012) used a pre-test, post-test design to
determine the effects of the ComAlong program (a packaged parent training programme) on the
responsivity of parents of children using AAC. They coded 105 videos obtained from the
ComAlong programme. From the videos coded, parents who participated in the ComAlong
training showed a significant increase in their responsive communication with their children on
the Responsive Augmentative and Alternative Communication Style (RAACS) scale after
training. Two studies were conducted with SCEDs and specifically multiple probe designs (MP)
by Douglas and colleagues (2017; 2018), to determine the effects of online parent training on
amongst others, the frequency of parents responding to their child’s communication. In both
studies children had CCN and used AAC. Parents were trained to use the POWR strategy
(Prepare the activity and AAC; Offer opportunities for communication, Wait for the child to
communicate and Respond to the child’s communication). In both studies, intervention clearly
had a positive effect on the frequency of parent responses to their child’s communication on six
of the seven parents participating, with NAP values between 0.91 and 1 when comparing
baseline data to intervention phase data. Maintenance results from both studies showed some
variability – although five parents showed an increase in responding during maintenance, two
showed a drop, and data patterns for all parents remained variable or declining.
Limited maintenance of contingent responding was also observed in the current
investigation. For various reasons, it seemed that caregivers would still have benefitted from
further guided practice to establish their behaviours. A more gradual withdrawal of support (e.g.,
guidance on every second session) may have assisted them to maintain their skills better.

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9.2.2. The effect of the CgTP on caregivers offering communication opportunities to their
children in a 10-minute interaction
It was evident that none of the three caregivers used any of the specific strategies to
create communication opportunities (offering choices, providing brief turns or small portions,
and making a desirable item inaccessible) for their children before training. Medium effects for
the intervention were seen for Caregivers 1 and 3 and strong effects were seen for Caregiver 2. It
is clear that the intervention had a positive impact on the number of times the caregivers offered
the children opportunities to communicate using the three strategies. This is somewhat consistent
with what has been found in previous studies where caregivers increased the frequency with
which they offered communication opportunities to their children after they had received
training. Specifically, the studies by Douglas and colleagues (2017; 2018) also measured the
effect of parent training on offering communication opportunities. Both studies used single case
multiple probe design and the effects of the intervention were measured using the NAP metric.
Medium to strong effects were seen for the seven parents taking part in the two studies, with
NAP values ranging from 8.88 to 1.
In the current investigation, none of the three caregivers maintained the skill of offering
communication opportunities post intervention. The findings from Douglas et al. (2017; 2018)
were somewhat more positive. In the 2018 study, two of the three caregivers showed a decline in
offering communication opportunities during the maintenance condition, while one maintained
the skill. In the 2017 study, one caregiver did not maintain the skill; one caregiver maintained the
skill on the same level as during intervention and the other two caregivers showed an increase
during the maintenance phase.
It has to be noted that, in this investigation, only instances in which the specific strategies
(offering choices, providing brief turns or small portions, and making a desirable item
inaccessible) were observed, were counted as evidence of creating communication opportunities.
During baseline observations, the caregivers were not offering their children choices, providing
brief turns and small portions or making a desirable item inaccessible during the selected
routines and/or activities. However, this does not mean that the caregivers were not offering
opportunities for communication as other methods can be used to do so, such as asking
questions, requiring the child to name items, and providing an opportunity for a child to imitate

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(Sigafoos, 1999) which they were already doing. A wider definition may have captured more
instances of caregivers doing so. This may also have contributed to better maintenance as
caregivers may have found it easier to expand on behaviours that were already in their repertoire.
Communication opportunities that parents were taught in the Douglas et al. (2017; 2018) studies
included asking the child questions, commenting about what was happening in the activity, and
offering the child choices. This may also be a reason why results in this investigation differed
from those found by Douglas and colleagues (2017; 2018).

9.2.3. The effect of the CgTP on the frequency of caregivers modelling aided language input
to their children in a 10-minute interaction
Although caregivers were receiving SLP services in the government hospitals, none of the
caregivers were exposed to AAC and how to model aided language input to the children living
with CCN prior to training. The intervention showed strong effects for all three caregivers.
Caregivers in this investigation modelled aided language to their children during intervention by
pointing to the relevant symbols on the communication board while verbalising the word during
the activity they self-selected for the duration of the investigation.
When comparing the results obtained from this investigation to those of other studies,
similarities were observed. In a study by Senner et al. (2019), researchers used a pre-test post-
test research design to measure the effect of parent instruction on modelling AAC use in
naturally occurring activities. The parents were taught to implement the strategy that includes
using Slow rate, Modelling AAC, Respect and reflect, Repeat, Expand and Stop (SMoRRES). An
increase in the utterances modelled by the parent on the child’s SGD was seen for all four
parents. Parents increased their aided models when they used the children’s SGDs after they
were trained to implement partner augmented input (PAI) strategies using the child’s SGD.
Rosa-Lugo and Kent-Walsh (2008) employed a single case multiple probe design across
participants to determine the effects of a parent instructional programme on the communication
of two Latino parents and their Latino children using AAC. In this investigation they taught
parents how to use AAC modelling, expectant delay, open ended questions, and responsiveness
to the child’s communication. The parents implemented the strategy with 90% accuracy and
maintained the skills, including AAC modelling.

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Kent-Walsh and colleagues (2010) taught parents to implement the RAAP strategy and
embed modelling of AAC during a story book reading routine. They used a single case multiple
probe design across participants to train the parents. The parents implemented the strategy with
90% accuracy and maintained the skills including AAC modelling in all the conditions
(intervention, generalisation and maintenance).
In the current investigation, aided modelling was not well-maintained after intervention, and
all three caregivers showed some deterioration of the frequency with which aided modelling was
provided. This finding contrasted with the findings by Rosa-Lugo and Kent-Walsh (2008) and
Kent Walsh et al. (2010). Once again, it seems that more guided practice sessions and a more
gradual fading of support may have helped parents to better maintain this skill.

9.3. The effects of caregiver training on the child variables

The results of the CgTP showed that the intervention had medium to strong effects for the
concomitant variables measured for the children in the dyads. These variables were the number
of times the child takes communicative turns and the number of times the child used augmented
output during the 10-minute interaction. As none of the variables were maintained post
intervention for the caregivers, it was to be expected that none of the variables were maintained
for the children due to the reciprocal nature thereof.

9.3.1. Effects of caregiver training on the frequency of child communicative turns during the
10 minutes interaction
Although the children were taking communicative turns during intervention prior to the
caregiver training (i.e., baseline), the number of turns increased for all children during the
intervention probes – showing that the training had a strong effect on this variable. An immediate
increase was seen for Child 1 and 3; however, a more gradual increase was seen for Child 2.
These findings are consistent with research showing that child communicative turns
increased after parents had received training on AAC strategies. Binger et al. (2008) reported that
children in their study increased the number of times they took communicative turns due to
parents employing expectant delay strategies. Other studies that showed an increase were Dodge-
Chin et al., (2022), Kent-Walsh, Binger, and Malani (2010), Nunes and Hanline (2007), and
Rosa-Lugo and Kent-Walsh (2008).

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Dodge-Chin et al., (2022) used a randomised single case multiple probe design across
four participants to assess the feasibility of a telepractice-based intervention using the RAAP
strategy across five dyads. They measured the effects of the strategy on the number of
communicative turns the children took during interaction as a secondary variable. The NAP
metric for child communicative turns ranged from 0.33 to 1.0 across the children within the
dyads, suggesting some weak and some strong effects. Weak effects were seen for Children 1 and
4, medium effects for Child 3 and strong effects for Children 2 and 5. Furthermore, some of the
children showed declines in maintenance condition whereas smaller and moderate changes were
also observed. The results of the current investigation are similar to those of Dodge-Chin and
colleagues’ study as the effects of the intervention varied across the participants. Some children
displayed changes in maintenance while others did not show any changes.
With regards to the child’s performance being variable, this was also observed in a study
by Douglas et al. (2013) where paraeducators were trained on two strategies (IPLAN [Identify
activities for communication, Provide means for communication, Locate and provide vocabulary,
Arrange environment, use iNteraction strategies] and MORE [Model AAC, Offer opportunities
for communication, Respond to communication, Extend communication]) in order to enhance
communication of the learners in their study. Commonalities with the results for this study were
seen regarding variability of the child’s performance on taking communicative turns (Douglas et
al., 2013), with some children’s performance remaining variable and not clearly well-maintained.
In a third study, Rosa-Lugo and Kent-Walsh (2008) used a multiple baseline design with
two dyads to determine the effect of a parent instructional programme on the communication of
Latino parents and their children. They used communication displays that are similar to the
child’s AAC system during storybook reading. The children showed an increase in their
frequency of taking communicative turns from baseline to intervention and also generalised this
skill and maintained it post intervention. It is to be expected that when caregivers do not show
maintenance of a skill, the children are likely not to maintain the skill because of the reciprocal
nature of influences that the child has on the caregiver and the caregiver on the child according
to the transactional model of development.

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9.3.2. Effects of caregiver training on the number of times the child used augmented output
during the 10-minute interaction
Although children had access to communication boards during baseline, they did not use
them or point to symbols on the boards prior to caregiver training. There was an immediate
change during intervention as compared to baseline for all the children. Overall, the intervention
had strong effects on Child 2 and 3; and medium effects on Child 1.
These results align well with previous studies where children began using their AAC
systems with their parents after the parents were trained to model the use of the child’s system
(Binger et al., 2008). Binger et al. (2008) aimed at investigating the effects of the instructional
programme on the multi-symbol utterances produced by Latino children with CCN. A single case
multiple probe design across participants was used. Children began producing spontaneous
multi-symbol utterances on the SGDs when their parents modelled AAC using their SGDs during
story book reading. Two of the children consistently used the multi symbol utterances during
maintenance and one child showed a decline.
In the study by Senner et al. (2019), authors set out to determine the effects of parent
instruction on modelling AAC use in natural contexts. A pre-test post-test design was used in this
investigation. An increase in children’s use of their SGDs was observed post parent training, but
it was not significant.
Some differences were observed in the Romski et al. (2010) study. The aim of this study
was to compare the performance of children with developmental delays who were assigned
randomly to a parent coaching intervention. The researchers evaluated differences in the
performance of the children on augmented and spoken word size and use thereof, vocabulary
size, and communication interaction skills. The participants were divided into the augmented
input (AI) group, augmented output (AO) and the spoken communication (SC) groups. Parents
were coached to model SGD use in AI group; to use hand-over-hand prompts in AO group, and
to focus on producing speech sounds in SC group. Children in the AO group used the augmented
words more than children who were assigned to the AI group.

9.4. Reasons for the results obtained

The effects of the intervention on caregiver and child variables may have been influenced
by the characteristics of the CgTP, and may also be explained from its theoretical underpinnings.

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9.4.1. Characteristics of the CgTP

Various characteristics of the CgTP may have contributed to the effect it had both on
caregivers and on children. These characteristics include the instructional strategies used, the
individualised nature of the programme, the frequency and duration of the training and guided
practice sessions, as well as the context and activity settings chosen for training.
The instructional strategies employed in the delivery of the CgTP are in line with those
that have been reported to be useful for training of caregivers in LMICs and high income
countries (HICs) (Barlow et al., 2012; Kaminski et al., 2008; Lundahl et al., 2006; Reichle et al.,
2019). Instructional strategies such as feedback, observation, and reflection were employed and
they are considered mostly behavioural in nature. They were reported to be effective when used
in coaching families (Sheldon & Rush, 2010).
Regarding delivery format of the CgTP, caregivers were trained individually. Although
individualised training may have had various advantages and disadvantages when compared to
group training methods, both formats have been found to help caregivers gain the necessary
skills for addressing problem behaviours in younger and older children (Cotter et al., 2013;
Lundahl et al., 2006). Individualized training can be readily tailored to the needs of specific
caregivers and children. In this investigation, training was similar, though individualised for each
caregiver-child dyad, because the caregivers chose activities in which they would implement the
strategies they had learnt. Individual training is effective as the caregiver’s needs can be
accommodated more readily than in group training. Also, training can be tailored to meet the
caregiver’s learning pace and level of literacy.
As far as possible, baseline probes, intervention probes and maintenance probes were
conducted on a daily basis. However, the scheduling of daily sessions was motivated partly by
practical constraints because the investigation was conducted during the Covid-19 pandemic.
The researcher had to wait for interprovincial travel bans to be lifted in order to travel to the
province where the investigation was conducted and be able to conduct the sessions in the
caregivers’ homes. As a result, the time frame within which the training and data collection could
be conducted was somewhat limited. In a recent study, parents recommended that the frequency
of the sessions should be reduced to less than three times a week as more engagement than that
was too intensive for them (Timpe et al., 2021). This may explain the dosage of most parent

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training studies ranging from once weekly (Bornman et al., 2001; Anna Jonsson et al., 2011;
Senner & Baud, 2017; Tait et al., 2004) to twice a week (Romski et al., 2010). Studies that
included a frequent dosage for shorter periods typically ranged from two to three weeks in total
and also tended to train parents on at least two variables and strategies that are packaged such as
the RAA, RAAP and SMoRRES. The current investigation also trained caregivers on multiple
strategies. This may have led to some information overload; caregivers could possibly give
attention to one strategy and neglect another during an intervention session with their child (for
example, the caregiver could focus on responding to the child and neglect to offer
communication opportunities to their child as she might not be able to implement all the
strategies at once).
Caregivers did not maintain any of the learnt strategies post intervention, and children
therefore also did not maintain any of the behaviours measured. It is apparent that caregivers still
required the feedback and guided practice provided during intervention probes in order to
continue using the strategies they were taught. A longer period of providing this support and a
gradual fading of this support may have assisted caregivers to maintain skills. Booster sessions
with feedback and guided practice could have been implemented when the first probe in
maintenance returned to baseline or was lower than the highest point in baseline in order to
maintain the skill. Booster sessions have been used in various previous caregiver training
programmes and have assisted in enabling caregivers to maintain learnt behaviours (Kaiser &
Hancock, 2003; Thunberg, 2013). Although external constraints (time and Covid-19 pandemic)
made this challenging, this should be a consideration for future trainings.

9.4.2. Theoretical underpinnings: Transactional Model of Development

Visual analysis results as shown in Chapter 8, Figure 8.1, show the reciprocal relationship
between the child and the caregiver. It is evident that, in many instances, caregiver and child
variables follow a similar pattern, and seem to mirror each other. The frequency with which the
child took communication turns, for example, seemed to mirror the number of caregiver
contingent responses. Although maybe less obvious, the number of times the children pointed to
symbols on the board at times seemed to mirror the aided models provided to the child. It is clear
therefore, that a change in parent behaviour brought about a change in child behaviour. This can
further be supported by the premise of the transactional model of development (Sameroff, 2009),

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which proposes that there is a transactional influence between the caregiver and the child within
the environment that affects child development. Child development (including communication
and language) is viewed as a product of the constant interactions between the child and the
experiences provided by the family and the context. Thus, when the caregiver responded less, the
child showed a decrease in communication turns and vice versa. The same could be seen on the
influence the caregiver had on the child and the child on the caregiver when AAC was modelled
versus the number of times the child used augmented output.
Training caregivers to increase or implement certain behaviours in interaction with their
children can therefore have a positive effect on the child’s communication behaviours, and, in
turn, further encourage caregivers to maintain and increase these behaviours. The success of the
programme can therefore be attributed to the training, but also to the manner in which parents
implemented the behaviours and then experienced positive changes in their children. Likewise, it
was apparent that, on days when children did not respond positively, caregivers had more
difficulty implementing the strategies they had been taught.
Renner (2003) outlined Vygotsky’s cultural historical perspective with regards to
communication development using alternative methods. To compensate for limited or missing
speech, alternative forms of communication should be implemented. However, these forms need
to enable the expression of the same communication functions that children without disabilities
would express, and also need to be aligned to the child’s cognitive, motor, perceptual and
linguistic skills in order to be implementable by the child (Renner, 2003). In the current
investigation, children learnt to use the activity-specific communication board to express
themselves. It seems therefore that the alternative communication form was well-aligned to their
abilities. Even Child 1 and 2, whose communication skills were on a pre-symbolic level, were
able to start pointing to picture symbols, thereby using a more symbolic form of communication.
The inclusion of different parts of speech potentially widened the types of communication
functions that could be expressed, such as comments, requests and social messages. Although
Child 3 also started pointing to pictures on the board, access to 20 vocabulary items may have
been somewhat limiting for him in view of his communication skills falling at the level of
abstract symbols. AAC systems that are too limiting will not be used and are likely to be
abandoned (Moorcroft, Scarinci et al., 2021, Moorcroft, Meyer et al., 2021).

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The alternative form implemented should also be appropriate to the context and partners.
These aspects were considered in the planning and design of the intervention and the materials.
Given that the training was implemented in a rural setting of Vhembe, the researcher chose low-
tech aided AAC to implement in the investigation. This was deemed more appropriate and
sustainable, because the communication boards are affordable and accessible to the participants.
Low-tech aided AAC has been implemented in various intervention studies, including some
conducted in South Africa (Dada & Alant, 2009; Tönsing, 2016; Tönsing et al., 2014).
Furthermore, Vygotsky focuses on the importance of social interaction with people in the
environment for cognitive and language development. Development is rooted in a cultural
environment. This implies that language and communication are associated with the shared
social structures embedded in the culture, which results in language development being
culturally and socially driven. When a child with disabilities interacts with a competent member
of a particular culture who could be an adult (which in the current investigation was their
caregiver), the social environment affords the child with a model of culturally-valued skills and
abilities. The intervention also took place within the naturalistic environment of each child, at
their home within their daily routines. Hence, AAC was implemented in their natural routines
within the cultural and social environment. The care taken in culturally validating the current
intervention before delivery (see Section 9.4.3) could therefore have contributed to the success of
the intervention.

9.4.3. Social and cultural validity of the intervention

The current study employed a sequential process of development and evaluation to ensure
that the intervention would be socially and culturally valid. Thomas and Rothman's (1994)
Design and Development paradigm was used to guide the development of the intervention
(CgTP). This framework has seven steps, and this study used the first four steps which are: (a)
problem analysis and project planning, (b) information gathering and synthesis, (c) programme
design, (d) early development and pilot testing.
In the first phase of this study, Vhavenda cultural stakeholders were interviewed, in
order to identify the cultural practices of Vhavenda with regards to caregiver-child
communication interaction, as well as their beliefs about children living with a communication
disability. Furthermore, the researcher wanted to obtain their perceptions on the Vhavenda

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cultural conventions of typical caregiver-child communication interactions; the cultural beliefs

of Vhavenda about communication disorders, forms of communication and interventions for
communication disorders; and to determine acceptability of the proposed programme
strategies and considerations for cultural appropriateness of the CgTP. This process served
both the cultural and social validation in the initial phase.
Furthermore, instructional strategies to train caregivers (identified from a scoping
review of the literature) were presented to the Vhavenda cultural stakeholders for input on
what they regarded as appropriate and not appropriate for their context. Recommendations on
how to make the strategies and training acceptable to the target populations were drawn from
this exercise. The researcher designed and developed the CgTP based on this input.
Ensuring that interventions aimed at supporting child development are culturally
appropriate is integral to ensure that these interventions respect and strengthen the cultural
patterns of child rearing, rather than imposing ways of interacting with children that are
incompatible with the community’s values (Morelli, Bard et al., 2018). Attempting to
understand caregivers’ lived reality before “subjecting them to treatment” is essential to avoid
reducing them to treatment recipients and negating the experiential and cultural knowledge
they bring (Pillay & Kathard, 2018). Rooted in Western and colonial approaches,
communication interventions often presuppose a specific world view (scientific, positivist) and
therefore appear incompatible with other world views (Pillay & Kathard, 2018). Stakeholders
who participated in the interviews seemed aware of these world view clashes as they
juxtaposed medical and Christian worldviews with traditional cultural ones. At times there
were even signs of internalized oppression as stakeholders seemed to suggest that traditional
views were perceived as unhelpful to foster child communication skills. While the interview
data was helpful to adjust some of the proposed strategies and materials, it has to be noted that
many aspects of the programme (e.g., quantitative way of measuring success) were still rooted
in Western models, even though an attempt was made to have stakeholders’ input in
programme development.
The second activity related to social validation was the expert review process. SLPs
practising in Vhembe district were recruited to obtain an informed opinion about the
relevance, appropriateness, and potential effectiveness of the proposed CgTP for the target
population. They were requested to comment and recommend changes on the delivery format,

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content and materials. Changes were made in accordance with their suggestions. Furthermore,
caregivers were requested to choose an activity they would like to use for the duration of the
investigation. Caregiver 1 chose a morning routine, Caregiver 2 a mealtime routine and
Caregiver 3 a gardening (watering the garden) activity.
The last activity entailed an evaluation of social validity by participants. Caregivers were
given a post-intervention survey based on the Treatment Acceptability Rating Form-Revised
(TARF-R) (Ogilvie & McCrudden, 2017). There were 17 closed-ended questions using a 5-point
Likert scale and four open-ended questions that asked caregivers about what they liked, if they
wanted to change anything about the programme, and whether the programme had positive and
negative consequences. Lastly, they were asked to rate their level of satisfaction.
The results of the post-intervention survey showed that the caregivers were satisfied
with the training in general. Moreover, they deemed the CgTP to be socially valid in terms of
the constructs measured by the TARF-R; namely understanding, effectiveness, acceptability,
reasonableness, willingness, disruption/time and side effects. Research has shown that social
validity in AAC interventions is an important aspect as it is instrumental to closing the gap
between research and practice (Biggs & Hacker, 2021).
Social validation has been carried out in AAC intervention research and the results of
this study can be compared to other studies (see review as discussed in Chapter 4) that
involved processes before and after the interventions. It was reported that the majority of the
studies evaluate social validity at the end, rather than taking it into consideration from the pre-
intervention to the post-intervention stage.
The process then proceeded to socially validate the intervention could also have
contributed to the effectiveness of the intervention. Thus, some factors that affect the
implementation of interventions in real-life situations such as the setting, the demographic
profile of the participants and other psychosocial factors were also considered in the
conceptualisation of the current study. These factors cannot be controlled during experimental
trials, but they would manifest when implementing these interventions in real life.
Intervention research is often presented as a progression from studies that are high in
internal validity and low in external validity to those that then attempt to implement the
intervention in ‘real life.’ The implication is that that the effectiveness of an intervention needs to
be established in rigorously-controlled, internally-valid studies before applying such

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interventions in less controlled environments (Damschroder et al., 2009; Peters et al., 2013).
However, the caregiver-mediated intervention developed and implemented in the current study
needs to be environmentally (caregiver) driven, and not only environmentally mediated. For this
reason, it was important to consider contextual fit during the design and development of the
intervention so that the intervention will have uptake and sustainability with the target population
and context. Therefore, this intervention balanced both internal validity and some aspects of
external (ecological) validity when designing the intervention (Rothwell, 2005), though external
validty was not the main purpose of this study.

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CHAPTER 10
CONCLUSION

10.1 Introduction
The main aim of this study was to develop and evaluate the effectiveness of a culturally
and linguistically appropriate training programme designed to train caregivers of children aged
2-6 years with CCN to implement AAC in a low-income rural context of South Africa. A three-
phase mixed methods exploratory design was used.
This final chapter of the thesis provides a summary of the results obtained from the three
phases of the study as well as the conclusions drawn from these phases. Thereafter the clinical
implications are highlighted followed by a critical evaluation of the study after which
recommendations for future research are discussed.

10.2 Summary of the results and conclusions

10.2.1. The summary of this thesis is organised according to the three phases of the study.1
Phase 1: Exploratory phase
The aim of the exploratory phase of the study was to map the information available in the
literature regarding the nature of caregiver training programmes designed for caregivers of
children living with CCN and to explore the cultural practices of Vhavenda with regards to
caregiver-child communication interaction, as well as their beliefs about children with
communication disabilities. The exploratory phase comprised of two studies. The first study
entailed a scoping review of the published literature documenting programmes and approaches
that focused on training caregivers to implement AAC. The second study involved conducting
interviews with cultural stakeholders to understand the cultural practices of Vhavenda with
regards to caregiver-child communication interaction, and their beliefs about children with CCN.
Phase 1 concluded by highlighting the significant elements of caregiver training
approaches with regards to the training recipients, the delivery format and content of the training
as well as instructional techniques used, and the outcome measures reported. Furthermore, the
review identified caregiver-implemented intervention strategies that were commonly used for
young children living with CCN and these were presented to the stakeholders during the
interviews, for validation. An instructional protocol by Kent-Walsh and McNaughton (2005) was

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also identified and this was used to inform how the training should be conducted and what
should be included to facilitate the training. The cultural stakeholder interviews provided
information regarding Vhavenda cultural practices regarding typical adult-child interactions,
Vhavenda cultural views about communication disability and intervention, and commentary on
the applicability of the provisionally-proposed intervention strategies. The data collected in the
exploratory phase was incorporated into the initial development of the CgTP.

10.2.2 Phase 2: Development phase

In this phase, the CgTP was developed. An expert review was done with SLPs practising
in Vhembe to ensure relevance and applicability of the CgTP. The experts validated the CgTP
and deemed it relevant and applicable for caregivers living in Vhembe. A pilot study was
conducted with one caregiver-child dyad to ensure that the preliminary procedures for
programme implementation, materials for screening and measurement were feasible. A number
of small changes were made to materials and procedures ahead of the main study.
The development phase ensured that caregivers were trained using a culturally,
contextually and linguistically appropriate CgTP. Furthermore, the results from the pilot study
ascertained the feasibility and appropriateness of procedures, measures, material and analysis of
data. The recommendations were then implemented in Phase 3.

10.2.3 Phase 3: Evaluation phase

In the final phase, a SCED, specifically a multiple-probe design across three caregiver-
child participant dyads was used to measure the effects of the CgTP on five variables. The
independent variable (IV) for this study was the caregiver training. The DVs measured in relation
to caregivers were: (a) frequency of contingently responding to the child, (b) frequency of
offering communication opportunities, and (c) frequency of modelling aided language input – all
measured within a 10-minute caregiver-child interaction. The concomitant effects of the training
on the child were measured by establishing (a) the frequency of communicative turns taken by
the child (b) the frequency with which the child uses augmented language output during a 10-
minute interaction. The dependent variables were measured by means of collecting probes during
baseline, intervention and maintenance conditions. The intervention was introduced in a
staggered manner across the three caregivers to show experimental control and to establish if

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there is a causal relationship between the IV and DV. The first baseline probes were collected on
the same day for all three dyads. CCD 1’s baseline probes were collected daily until stability was
reached; thereafter intervention was introduced. The intervention consisted of two-day training, a
two-day break afterwards wherein the caregivers were supposed to submit a homework activity.
This was followed by eight guided practice with feedback sessions. Intervention probes were
collected first, before every guided practice with feedback session. Baseline probes for CCD 2
and CCD 3 continued to be collected at intervals. Three consecutive baseline probes were
collected for CCD 2 once CCD 1 neared the end of their intervention phase. Three consecutive
baseline probes were collected for CCD 3 once CCD 2 neared the end of intervention.
The intervention showed medium to strong effects on the variables that were outlined.
Strong effects were observed for modelling aided language input for all the caregivers; offering
communication opportunities for Caregiver 2; contingent responding for Caregiver 1; child
communicative turns for all three children; and child using augmented output (CUAO) for Child
2 and 3. Medium effects were seen for Caregivers 1 and 3 for the variable offering
communication opportunities; Caregivers 2 and 3 for contingent responding; and Child 1 for the
variable child using augmented output. It can therefore be concluded that the caregiver training
was effective in changing the behaviour of caregivers and also the communication behaviours of
their children during the chosen everyday activities. However, effects were not maintained post
intervention for any of the 3 parent-child dyads.
In addition, the social validity of the intervention was determined using a survey adapted
from the Treatment Acceptability Rating Form -Revised by Reimers and Wacker (1992). The
post intervention survey completed by the caregivers indicated that the training programme had
high social validity. The caregivers reported that the CgTP facilitated their understanding and
knowledge, and that they experienced the training programme as effective, acceptable and
reasonable. They also reported that they were willing to teach these newly-learnt skills to other
family members, and that they did not experience the CgTP as being disruptive to their daily
schedules. No negative side effects were reported and all caregivers stated that they were
satisfied with the training.
It can be argued that various factors contributed to the success and effectiveness of the
intervention. The process followed in designing and developing the intervention followed the
evidence-based practice framework. This framework outlines the significance of considering

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research evidence, combining it with stakeholder input and the researcher’s expertise as a
clinician. The researcher based the study on previous research (scoping review), theoretical
grounding (child development theories, eco-cultural theory and adult learning theory) together
with the process of ensuring cultural and contextual congruence through the cultural
stakeholders’ interviews (Chapter 5). Furthermore, the programme developed by the researcher
underwent an expert review process (Chapter 6) wherein SLPs provided input to ensure usability
and feasibility, as well as cultural and contextual appropriateness of the CgTP. In order to ensure
caregivers’ input, the caregivers who took part in Phase 3 were also given the opportunity to
choose the activities during which they wanted to learn to foster the use AAC with their children
in their daily routines.
One possible reason why caregivers did not maintain the skills they were trained in post-
intervention may be that the withdrawal of support offered during guided practice was too
abrupt. A more gradual fading of support may have led to better maintenance. Lack of time
precluded this possibility in the current study.

10.3 Implications for practice

The development and evaluation of the CgTP was a first attempt to rigorously develop
and experimentally test the effectiveness of a training programme aimed at training Vhavenda
caregivers to implement AAC strategies appropriate to beginning communicators. The results of
the study suggest that the two-day initial training combined with subsequent guided practice
sessions during daily activities in the home context afforded parents the support needed to
implement strategies that support their children’s communication and use of AAC. All children
participating in the study were aged between 2 and 6 years and were intentional though not
necessarily symbolic communicators. All caregivers had literacy skills in English and/or
Tshivenda (by self-report) on at least a Grade 7 level. The lack of maintenance of strategy use
suggests that support may be needed for a longer period of time and may need to be gradually
faded over time rather than being withdrawn completely after eight sessions.
These results may be useful to clinicians who are supporting children in need of AAC and
their families. They may be able to incorporate aspects of this programme into their clinical
practice, in order to support the implementation of AAC for the benefit of beginning
communicators and their caregivers in the South African context. This study showed that AAC

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has benefits even for beginning communicators on a pre-symbolic level, and that AAC does not
need to be the last resort once interventions focusing on improving spoken language skills have
failed. Specific aspects of the programme are flexible and amenable to be customised and
applied in ‘real world’ clinical and home settings. For example, parents could choose their
preferred routines and support was provided in actual home settings rather than in a controlled
laboratory setting. Despite lack of control over variables such as the presence of other family
members, and other contextual factors, effects were still achieved, suggesting that the
intervention is robust enough to not be unduly affected by such variables. Also, while guided
practice sessions were intended to be implemented daily during weekdays, amendments were
made to the scheduling of sessions due to factors such as family availability and child health.
Although this may have reduced experimental control, such scheduling constraints are a common
occurrence in clinical practice, and therefore may have increased external validity of the study.
The process followed in ensuring cultural appropriateness through stakeholder inputs and expert
review also strengthens the external validity of the programme, and the use of both English and
Vhavenda during training and implementation ensured linguistic congruence between service
providers and recipients. The use of accessible language, and engaging training strategies such as
videos as well as memory strategies such as a mnemonic may have contributed to the
effectiveness and these may easily be applied in clinical practice. The high social validity ratings
given by parents suggest that they valued the intervention and would be likely to accept or
engage in a similar intervention being offered to them through a health service system.
At the same time, clinical practice and research conditions do typically differ, and
amendments may need to be made to the CgTP to be compatible with the constraints of clinical
practice. For example, the intensity of the treatment (multiple sessions weekly) and the location
(in the home) may need to be changed in accordance with the resource and time allocations
afforded to clinicians in public health settings. Group rather than individual training may need to
be considered. Telepractice options rather than face-to-face training may also need to be
considered when caregivers and clinicians are unable to meet due to geographical distance,
transport costs or other reasons (e.g., pandemic). However, making such amendments may affect
the effectiveness of the CgTP, and additional implementation research (Peters et al., 2013) may
be needed to understand how the CgTP can be adapted for clinical practice and yet retain its
effectiveness. However, the current study lacks the larger context to say what comes next.

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The lack of maintenance should alert clinicians that eight sessions of guided practice may
not be enough to promote a sustained behaviour change in caregivers, and that they may need
additional support. Besides more sustained guided practice sessions, the training on the strategies
could be adapted and broken down in individualised sessions so as to allow for consolidation of
one skill at a time over time.
The CgTP was developed in a way that it is flexible and can be used to train caregivers to
implement AAC with their children with CCN. The strategies of the programme can be
implemented by caregivers with children diagnosed with developmental disorders from an early
age; that is earlier than two years of age. The delivery of the CgTP can be conducted individually
or in a group format in the home context or hospital setting. Furthermore, the CgTP can also
include training of various communication partners, not just caregivers but other family
members, in line with family-centred practice. The instructional protocol used to deliver this
study allows for adaptation and modifications of components depending on the contexts. The
training can be adapted and allow caregivers to be trained using online and/or tele-rehabilitation
platforms. The training on the strategies can be adapted and broken down in individualised
sessions so as to allow for consolidation one skill at a time over time. Additionally, the strategies
that were included in the programme allow for training and implementation using a multi-step
mnemonic in different activity-based settings that caregivers and children engage in daily.
The CgTP was developed in a way that it is flexible and can be used to train caregivers to
implement AAC with their children with CCN. The strategies of the programme can be
implemented by caregivers with children diagnosed with developmental disorders from an early
age; that is, as early as two years of age. The delivery of the CgTP can be conducted individually
or in a group format in the home context or hospital setting. Furthermore, the CgTP can also
include training of various communication partners, not just caregivers but other family
members, in line with family-centred practice. The instructional protocol used to deliver this
study allows for adaptation and modifications of components depending on the contexts. The
training can be adapted to allow caregivers to be trained using online and/or tele rehabilitation
platforms. The training on the strategies can be adapted and broken down in individualised
sessions so as to allow for consolidation of one skill at a time over time. Additionally, the
strategies that were included in the programme allow for training and implementation using a

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multi-step mnemonic in different activity-based settings that caregivers and children engage in
daily.

10.4 Evaluation of the study

The strengths and limitations will be discussed in the sections following.

10.4.1 Strengths of the study

This study is the first of this kind aimed at developing, implementing and evaluating a
caregiver training programme in South Africa using an experimental design that enhanced the
control of many threats to internal validity. South Africa is a diverse country, also referred as
“rainbow nation”, with 11 officially languages and diverse cultures. The context of this study is
Vhembe district in the Limpopo Province of South Africa, which is largely populated by
Vhavenda, Tsonga and BaPedi. The Limpopo Province is largely rural and the majority of the
individuals living with disabilities and CCN rely on the poorly-resourced public healthcare
system to access rehabilitation services. This study makes an important contribution to the field
of AAC intervention literature as it expands the focus of AAC interventions to non-Western,
hitherto under-served contexts. Furthermore, the current study adds to the body of evidence
regarding the effectiveness of AAC interventions that are culturally and contextually appropriate
to train caregivers of young children living with CCN in rural contexts.
The CgTP went through an iterative process to ensure social validity with various
stakeholders. The process began with research-based evidence wherein the researcher conducted
a scoping review to identify various aspects of caregiver training in implementing AAC. From
the scoping review evidence, the researcher conducted interviews with cultural stakeholders to
partly validate and seek their opinions regarding the cultural appropriateness and contextual
relevance of the strategies so as to inform programme development. Furthermore, an expert
review of the CgTP was conducted with SLPs practising in Vhembe to ensure its feasibility and
acceptability. This process was followed by caregivers being asked in the screening process to
identify activities that they engage in with their children as well as asking them to choose an
activity that they would like to be trained on. In doing so, the researcher included the caregivers’
voices in the research. After caregivers were trained, they also voiced their perceptions on the
various constructs that validated the programme.

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Caregivers’ voices were important and this confirms the need to respect the adage of
“Nothing about us without us.” It can be concluded that the training programme that had
caregivers been trained in English only; and had the researcher not adhered to the
recommendations of the interviews, expert review process and pre-training information gathering
sessions, the training programme would not have been as effective as it was. The current study
bridges the gap from research to practice by highlighting that when due processes of social and
ecological validity are followed, experiment-based interventions can be implemented and will be
effective in natural environments. This was evident in the results obtained from the
implementation and use of the CgTP in training caregivers of children living with CCN who
require AAC in low-income contexts during the intervention condition. Research evidence has
shown the benefits of introducing AAC early for children living with CCN (Branson &
Demchak, 2009; Romski et al., 2010) and the benefits of AAC intervention in these contexts
(Bornman et al., 2001; Gona et al., 2013b; Zuurmond et al., 2018). Some of the benefits of this
intervention include bringing awareness of AAC in the contexts (Myers, 2007; Sansosti et al.,
2014), affording the children alternative forms of communication which will aid them in being
integrated within their communities, afford them an opportunity to participate with their peers
within their communities, as well as, afford them entrance to education, which will later translate
to employment.
A number of characteristics of this programme may have made it specifically suitable to
the target population. The material used for the training accommodated various characteristics of
the participants (caregivers) such as language and level of education. The material and content
were translated to Tshivenda and the expert panel gave input on the Tshivenda material for ease
of understanding, cultural and contextual appropriateness as well as acceptability. Caregivers had
a choice of the language of training. Furthermore, the constructs (understanding, effectiveness,
acceptability, reasonableness, willingness, disruption/time, side effects and overall satisfaction
with training) evaluated for social validity showed that the programme was socially valid.
The principles of adult learning were integrated into the training of the parents,
supplemented by an adaptation of the Kent-Walsh and McNaughton (2005) instructional protocol
to guide the study. This protocol is evidence-based and has been used to guide training of parents
from diverse cultural backgrounds, specifically Latino, African American parents (Binger et al.,
2008; Kent-Walsh, Binger, & Hasham, 2010; Kent-Walsh, Binger, et al., 2015).

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The intervention took place in the homes of the participants, thus reducing the stress and
costs to caregivers associated with travelling. It is noteworthy that the study took place during
the Covid-19 pandemic when the restrictions for travel were lifted. Given the nature of co-
morbid conditions that affect children living with DD and CCN, the researcher could not risk
cross infections, and thus the study was conducted at the homes of the participating caregivers,
even though there were possibilities of conducting the study in central places such as primary
healthcare clinics or the hospitals where they normally receive services.
The use of low-technology AAC systems in this study was a stepping stone towards the
possibility of using mid to high-technology AAC systems in the South African context. The low
tech AAC boards were cost effective and portable as the initial starting system. It was easy for
caregivers to model the use of aided AAC to their children in the activities they chose. At the end
of the intervention, caregivers were given extra communication boards for use in other activities
that were not part of the study.
The experimental design used to evaluate the effectiveness of the CgTP was a single case
multiple probe design across three participants. Three independent opportunities were afforded
by this design to observe a change in the dependent variables, thus giving it experimental
control. This increases the internal validity as it is likely that changes observed in the dependent
variables are indeed the result of the intervention.
The procedural fidelity of the administration of the probes as well as all intervention
activities was high. An independent observer found that, on average, 88-100% of the steps were
accurately executed. This further strengthens the internal validity of the study.
The use of effect size estimates (NAP) and confidence intervals, together with visual
analysis, provided a robust way of analysing results and strengthening confidence in the effects
of the training programme..
Although there was some homogeneity in the participant group in terms of the presence
of AAC, there was also variability. For example, the children had different diagnoses including
cerebral palsy, intellectual disability and spina bifida, and they were from a heterogeneous
population with regards to their diagnoses. They were living with a variety of DD; their
communication abilities ranged from Level III to Level IV on the Communication Matrix; had a
variety of communication and language skills; and were aged between 3 and 6 years. This
suggests that the CgTP can be helpful to children with some variation in skills profile and age.

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However, the children could use the activity-specific communication boards effectively with
their caregivers.

10.4.2 Limitations of the study

The visual analysis showed that the participants did not maintain the skills during
maintenance condition. Lack of maintenance patterns could be as result of limited to no support
received by the caregivers during guided practice sessions. Also, the early withdrawal of support
before behaviours were more firmly established in the repertoires of the caregivers could allude
to the possibility of caregivers not maintaining the skills. Setting a learning criterion may have
ameliorated the possibly premature discontinuation of the intervention condition. Similarly,
booster sessions may have been appropriate once it became clear that the behaviours were not
maintained. However, neither option was practical within the time constraints of the study. It is
also possible that the repeated measurement during the same activity led to the participants being
reactive and bored, thus contributing to limited maintenance. Inclusion of generalisation probes
could have probably assisted the non-maintenance of the skills.
The researcher chose low-technology aided AAC systems for caregivers to implement
with the children without consulting with caregivers prior to implementation.
Conducting training with only three participants limits the generalizability of the results
to the larger population, though the intervention proved to be effective. Furthermore, focusing on
one activity during the training and collection of probes precludes any conclusions being made
about the generalizability of the skills to other activity settings. Despite the lack of generality
inherent in this study, it was necessary and prudent to examine the causal relation between the
CgTP and targeted outcomes using cost-effective methods before advancing the intervention
toward more expensive and larger studies that could produce greater generality potential.
Time constraints for conducting the study and timelines for completion of PhD studies
prevented the researcher from including a projected five CCDs, which could have shown
different results. Furthermore, instead of collecting intervention probes daily, the researcher
could have collected probes every second day. The results could have been affected by daily
repeated measurements because they tend to inhibit performance if there are no incentives or
reinforcement. No incentives were offered in this study for the caregivers and this could have
negatively affected results. Although there was some variability on the characteristics of

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children and caregivers, the selection criteria for the study were relatively strict, and therefore it
is not possible to generalise results to children who may be younger, older, or who have different
communication profiles.

10.5 Recommendations for future research

There are a number of recommendations for future research arising from this current
study. The current study sits in Phase III of the of the five phase model of intevention research by
Fey and Finestack (2009). This study showed evidence of early efficacy if the CgTP. The next
phase would to get evidence of later efficay (Phase IV) which is tested in contexts different to the
current one and then evaluate the effectiveness of the intervention in Phase V of the model.
It is always recommendable to attempt to replicate findings in subsequent SCEDs or in
experimental group designs, although the latter would be difficult due to the small size of the
target population. Replications of this SCED should include an amended training procedure aimed
at promoting stronger effects and better maintenance. This could be achieved by setting a learning
instead of a teaching criterion to ensure that a robust frequency of strategy implementation is
reached before treatment is discontinued. A condition of intermittent rather than continuous
guided practice support could be considered after the condition of continuous support, to establish
whether behaviour changes when support is not given during every session. Also, if maintenance
probes show a reduction in behaviour, booster sessions can be implemented to support a return to
levels of behaviour measured during intervention. Future replications, generalization probes could
be conducted in other activity settings of the caregiver’s choice. Aditionally, conducting social
validation with the caregivers before collecting baseline probes, during intervention and after
intervention, thus comparing the social validation at different times would ensure pre- and post-
social validity. Expert review with various stakeholders at different aspects of research will
provide the researcher with information pertaining to changes that need to be effected so as to
strengthen the validity of the intervention.

A further replication of the current study using SGDs instead of communication boards is
recommended. Studies have shown the effectiveness of using SGDs with younger
children. Currently, there is funding available for assistive devices (i.e., wheelchairs,
hearing aids) through the state tender. The Department of Basic Education through their

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tender system have managed to procure introductory AAC devices that can only be used
at the schools and cannot be taken home. In the public healthcare sector in South Africa,
there is a need for SGD provision on a larger scale and therefore a similar study might be
instrumental in establishing the effectiveness of training parents to implement SGDs in
the home context. Such studies would guide appropriate procurement and implementation
of SGDs for the benefit of beginning communicators in the rehabilitation services sub-
directorate.
Once the effectiveness of the CgTP has been better researched, implementation research
(Peters et al., 2013) may assist in converting the CgTP from its current form to a form that
can be rolled out on a larger scale in clinical practice. The involvement of role players like
Department of Health officials, service managers, heads of rehabilitation services in public
health institutions, as well as caregivers and family members through qualitative and
mixed-method approaches and/or participatory action research can establish feasible
methods to facilitate implementation in practice, and also assist in evaluating the effects
of such implementation.
A further replication of the current study using SGDs instead of communication boards is
recommended. Studies have shown the effectiveness of using SGDs with younger
children. Currently, there is funding available for assistive devices - including
introductory AAC devices in the public healthcare sector in South Africa, and therefore a
similar study might be instrumental in leveraging the procurement of more devices in the
rehabilitation services sub-directorate. This will afford children with CCN their
fundamental human right to communicate by ensuring access to a voice. This will, in
turn, give them access to education and employment.
In the current study, the researcher implemented an individual face-to-face training
model. At the dawn of tele-practice within rehabilitation services in the South African
context, it is recommended that the effects of repeating the CgTP training be evaluated,
using tele-health methods. Research is emerging in other LMICs on the use of tele-
practice models in providing interventions to children with CCN, and hence such a study
would expand the current body of emerging evidence that is needed to advance the field
of caregiver training in AAC.

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10.6 Summary
This chapter provided a summary of the study according to the three phases that formed
part of the exploratory sequential mixed methods design. It was shown how data collected from
published research and stakeholder interviews during the exploratory phase provided the basis
for the development of the CgTP during the development phase. The implementation and
evaluation of the programme as conducted during the last phase (using a single case multiple
probe design across participants) was also summarised and concluding remarks on the reasons
and factors that influenced the effectiveness of the CgTP on the caregiver and child variables
were outlined. A discussion of the clinical implications of the study was provided to illustrate the
significance of the study. Strengths and limitations as well as the recommendations for future
research that emerged from this study were discussed.

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 References

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257
 APPENDICES

APPENDIX A
Ethical Clearance From the Faculty of Humanities Research Ethics Committee

258
 APPENDICES

APPENDIX B
B1 Department of Health Limpopo Ethical Clearance

259
 APPENDICES

B2 Vhembe District Health Ethical Clearance

260
 APPENDICES

B3 Hospitals Ethical Clearance

261
APPENDICES

262
APPENDICES

263
APPENDICES

264
APPENDICES

265
APPENDICES

266
APPENDICES

267
 APPENDICES

APPENDIX C
C1 Search Strategy per Database
Database Hits Search terms

Academic search complete 638((((((((“((DE "P”RENTS") OR“ (DE "CARE”IVERS")) AND“ (DE "CH”LDREN"))
OR“ (DE "TEE”AGERS")) AND“ (DE "COMMUNICATIVE dis”rders")) OR“ (DE
"DEVELOPMENTAL disabi”ities")) AND“ (DE "PARENTING edu”ation"))
OR“ (DE "CAREGIVER edu”ation")) OR“ (DE "PROGRAM design (Educ”tion)"))
AND“ (DE "MEANS of communication for people with disabi”ities")) OR“ (DE
"MEANS of communication for the developmentally di”abled")) OR“ (DE
"COMMUNICATION devices for people with disabi”ities")
ERIC (EBSCO) 60 (((((“((DE "Care”ivers") OR“ (DE "P”rents")) AND“ (DE "Caregiver Tr”ining"))
OR“ (DE "Parent Edu”ation")) OR“ (DE "Parenthood Edu”ation")) OR“ (DE
"Pr”grams")) AND“ (DE "Communication Dis”rders")) OR“ (DE "Developmental
Disabi”ities")) AND“ (DE "Augmentative and Alternative Communi”ation")
PsycINFO 107 (((((“((DE "P”rents") OR“ (DE "Care”ivers")) AND“ (DE "Parent Tr”ining"))
OR“ (DE "Parenting ”kills")) AND“ (DE "Child Character”stics")) OR“ (DE
"Adolescent Character”stics")) AND“ (DE "Communication Dis”rders")) OR“ (DE
"Developmental Disabi”ities")) AND“ (DE "Augmentative Communi”ation")
PYSCARTICLES“5010 "Communication Dis”rders" “R DE "Developmental Disabi”ities")) AN“ (DE
"Augmentative Communi”ation") OR means of communication for people with
disabilities
FAMILY AND SOCIETY STUDIES 105 ((((((“((ZU "p”rents")) or “((ZU "care”ivers"))) and “((ZU "caregiver edu”ation")))
and “((ZU "ch”ldren"))) and “((ZU "communicative dis”rders"))) or “((ZU
"communicative disorders in adole”cence") o“ (ZU "communicative disorders in
ch”ldren") o“ (ZU "communicative disorders in i”fants"))) and “((ZU
"developmental”delay") an“ (ZU "developmental disabi”ities"))) and “((ZU "picture
exchange communication ”ystem"))) or “((ZU "communication devices for people with
disabi”ities"))
CINHAL 2 S23 AND s24 AND S31 AND (S25 OR S26) AND S27

268
 APPENDICES

Database Hits Search terms

MEDLINE 4

Health Source: Nursing/ 14 (((((((“((DE "CARE”IVERS") O“ (DE "P”RENTS")) AN“ (DE "PARENTING
Academic Edition edu”ation")) O“ (DE "CAREGIVER edu”ation")) AN“ (DE "pr”grams")) AN“ (DE
"CH”LDREN")) O“ (DE "ADOLE”CENCE")) O“ (DE ”YOUTH")) AN“ (DE
"COMMUNICATIVE dis”rders")) AN“ (DE "COMMUNICATIVE disorders in
ch”ldren" “R DE "COMMUNICATIVE disorders in i”fants")) AN“ (DE "MEANS of
communication for people with disabi”ities")) O“ (DE "MEANS of communication for
the developmentally di”abled")
Africa-Wide Information 4 (“((ZU "augmentative and alternative communi”ation") o“ (ZU "augmentative
communi”ation")) or “((ZU "means of communi”ation"))) AND (S5 AND S6)) AND
(S5 AND S6)
SOCIAL WORK ABSTRACTS 25 ((((((((((“((ZU "care”ivers") o“ (ZU "care”akers")) or “((ZU "p”rents")) ) and “((ZU
"parent tr”ining"))) or “((ZU "parent training p”ogram"))) and “((ZU "ch”ldren"))) or
“((ZU ”youth"))) or “((ZU "adole”cents"))) and “((ZU "communication dis”rders")))
or “((ZU "developmental disabi”ities"))) or “((ZU "developmental di”order"))) and
“((ZU "communication t”erapy"))) or “((ZU "early interv”ntion"))
SCOPUS 652 ( ALL ( parent* OR caregiver* ) AND ALL ( parent* AND traning OR parent*
AND education OR training OR program* ) AND ALL ( child* OR adolescen*
OR youth ) AND ALL ( little OR no AND speech OR development* AND delay*
OR disabilt* OR communicat* AND disorder* OR communicat*269an

269
 APPENDICES

Database Hits Search terms

wanangabilit* ) AND ALL ( augmentative AND alternative AND communication

OR aac OR aided AND language OR aided AND language ) )

270
 APPENDICES

C2 Scopimg Review Summary of Studies

Authors, Research Participants: Training Outcomes
date and design Caregiver and
country Child variables Type of AAC Delivery: trainer; Caregiver(s) Child(ren)
implemented; training setting;
Skill/strategy group/individual;
trained; Routine online/face-to-
targeted face/self-study
1. Binger, Mixed methods: N = 3a: father (n = Aided; augmented Researchers; Increase in steps Increase in the
Kent-Walsh, Focus group and 1), mother (n = 2); inputb, milieu Individual; correctly number of multi-
Berens, Del SCED (MP Mage= 35 yrs; high teachingc and Face-to-Face implemented symbol messages
Campo & across school (n=2) and provide a means of produced in joint
Rivera, participants) bachelor’s degree communication in book reading
(2008) (n=1); the activityf; joint
USA book reading
Children: N = 3;
M=41 months;
Other genetic
syndromes

2. Bornman, Case report N = 1; mother; Aided; milieu AAC-trained SLP; Increase in level of Increase in
Alant, & 43 yrs; teaching and provide Clinic; Individual; questions frequency and
Meiring, psychologist; a means of Face-to-Face per’Bloom's appropriateness of
(2001) communication in the taxonomy and responses during
South Africa Child: N = 1; activity;book reading number of joint book reading
M=78 months; questions asked
CAS

3. Broberg, Quasi- N = 43 Both (aided and Two professional RAACS scale: None reported
Ferm & experimental: Comparison group: unaided); augmented course leaders (one Responsivity
Thunberg, Pre-test post-test N=6; input strategiesd, was SLP); Central increased
(2012) with comparison Experimental milieu teaching and meeting point; significantly for
Sweden group (non- group: N=37: father responsivity; Group (max 10); the experimental
random, non- (n=17), mother daily activities Face-to-face group from pre- to
equivalent) (n=20); post-training.

271
 APPENDICES

Authors, Research Participants: Training Outcomes

date and design Caregiver and
country Child variables Type of AAC Delivery: trainer; Caregiver(s) Child(ren)
implemented; training setting;
Skill/strategy group/individual;
trained; Routine online/face-to-
targeted face/self-study
M= 35 yrs; post-
high school (n=43)

Children: N = 28;
M = 48 months
(12-60);
NDD and Genetic
syndromes

4. Ferm, Mixed methods: Data for N = 48 Both (aided and Four professional Parents valued None reported
Andersson, Surveys and children were unaided); course leaders (two most aspects of
Broberg, interviews reported; augmented input were SLPs); the course. Positive
Liljegren & M = 48 months; strategies, milieu Central meeting point; changes in their own
Thunberg, NDD, unknown teaching and Group (max 10); communication.
(2011) diagnosis and responsivity; daily Face-to-face Parents reported
Sweden mixed diagnoses activities (not positive changes in
specified) the child’s
communication.

5. Jonsson, Mixed methods: Survey: N=65: Both (aided and Two professional Survey: Parent Case study: Children
Kristoffersso Survey and case father (n=22), unaided); course leaders (one was perceptions of the pointed to pictures on
n, Ferm, & studies mother (n=43); M= augmented input SLP); ComAlong boards (data of
Thunberg, 36 yrs; Post high strategies, milieu Central meeting point; boards were observations not
(2010), school (n=65) teaching and with positive. quantified)
Sweden Case Study: N = 4; responsivity; daily Group (max 10), face- 61% of the parents
M = 34 yrs; activities (not to-face reported positive
mother(n = 3), specified) changes in their
father (n = 1); communication.
272
 APPENDICES

Authors, Research Participants: Training Outcomes

date and design Caregiver and
country Child variables Type of AAC Delivery: trainer; Caregiver(s) Child(ren)
implemented; training setting;
Skill/strategy group/individual;
trained; Routine online/face-to-
targeted face/self-study
university degree (n 60% reported
= 4) positive changes
in their child’s
Children: Survey: communication.
data for 38 children
were reported;
M=37months; NDD
Case study: N = 3;
M = 62 months; CP
and ASD
Case study:
Parents used the
boards often and
engaged in aided
language stimulation
(data of observations
not quantified).
6. Bunning, Quasi- N = 7 (two Both (aided and Home; Individual; Parents perceived the Child competence in
Gona, experimental additional unaided); Face-to-Face child to be more communication as
Newton & single group caregivers were augmented input competent in measured by CP-A
Hartley, pretest-posttest included in the strategies, milieu communication- (parent-completed)
(2014) study but not in teaching, provide a related body increased from pre-
Kenya the review due to means of functions and to post-intervention
their children not communication in structures, and for all children, and
meeting criteria) the activity and activities. participation
responsivity; daily opportunities
Children: N = 7 activities (not showed increases for
(two additional 3 of 7 participants.

273
 APPENDICES

Authors, Research Participants: Training Outcomes

date and design Caregiver and
country Child variables Type of AAC Delivery: trainer; Caregiver(s) Child(ren)
implemented; training setting;
Skill/strategy group/individual;
trained; Routine online/face-to-
targeted face/self-study
children were specified); daily
included in the activities
study but not in
the review due to
not meeting
criteria); M = 90
months; NDD
7. Gona, Case series, Refer to Bunning Refer to Bunning et Refer to Bunning et Parent experiences None reported
Newton, qualitative et al. (2015) al. (2014) al. (2014) pre-and post-
Hartley & intervention: Some
Bunning, caregivers viewed
(2014) their skills and the
Kenya level of family
support and
connection
positively post-
training. Child
skills were viewed
positively post-
training

8. Quasi- N = 18: parents; Unaided; milieu Manual written by Parents rated all GAS scores (given
Calculator, experim“n”al "B" post high school teaching, researchers and four programme by parents) of four
(2016) design (N = 18) augmented input coaching by own goals important goals (related to
USA (qualitative Children: N = 18; and output; three SLP; pre-intervention, ENG use and
methods were Age range 3 -18 parent- and SLP- Home; Individual; and evaluated challenging
used for open- yrs; identified routine self-study and own effectiveness and behaviour ) showed
ended questions) situations SLP provided face- acceptability of the that children met or
to-face support exceeded the

274
 APPENDICES

Authors, Research Participants: Training Outcomes

date and design Caregiver and
country Child variables Type of AAC Delivery: trainer; Caregiver(s) Child(ren)
implemented; training setting;
Skill/strategy group/individual;
trained; Routine online/face-to-
targeted face/self-study
Genetic syndrome program positively expected scores as
(Angelman post-intervention. rated before training.
Syndrome)
9. Chaabane, SCED ( Multiple N = 2: mother (n Aided; augmented Variables setting and Correct No of correct
Alber- baseline design) = 2); M=37.5 yrs; input, augmented whether its group or implementation of improvisation:
Morgan & high school (n = output and provide individual was not the strategy: Increase in correct
DeBar 2) a means of reported; Researcher percentage of the improvisation
(2009) communication in (experimenter); correct increased from
USA Children: N = 2; the activity; Face-to-Face implementation of baseline to
M = 66 months; researcher the strategy was generalization 83%
ASD (experimenter); M=97% and 98 % and 84 %
routines not for both mothers, respectively, and
reported respectively. generalization
probes were 80-
100%.
10. Douglas, SCED (MP N = 4: father (n = Both (aided and 2 Parent-provided Child
Nordquist, across 1), mother (n = unaided); milieu communication communication
Kammes & participants) 3); M=37 yrs; teaching and opportunities: instances increased:
Gerde, high school (n = provide a means of Strong effects Strong effects were
(2017) 4) communication in were seen seen (NAP=1) for
USA the activity; play, (NAP=1) for Dyads B and D.
Children: N = 4; music anart Dyads A,B and D. Medium effects
M = 49 months; Medium effects were seen
CP and Genetic were seen (NAP=0.81 and
syndromes (NAP=0.88) for 0.91) for Dyads A
Dyad C. and C.
Responses to child
communication
Strong effects

275
 APPENDICES

Authors, Research Participants: Training Outcomes

date and design Caregiver and
country Child variables Type of AAC Delivery: trainer; Caregiver(s) Child(ren)
implemented; training setting;
Skill/strategy group/individual;
trained; Routine online/face-to-
targeted face/self-study
(NAP=1) Dyad
A,B,and D. .
Medium effects
were seen
(NAP=0.91) for
Dyad C.

Home; Individual
online self -study
with researcher
feedback on

276
 APPENDICES

Authors, Research Participants: Training Outcomes

date and design Caregiver and
country Child variables Type of AAC Delivery: trainer; Caregiver(s) Child(ren)
implemented; training setting;
Skill/strategy group/individual;
trained; Routine online/face-to-
targeted face/self-study
instructional
activities completed

Mixed methods: N = 6: mother (n Aided; augmented Researcher; Setting Percentage steps All children at least
Focus group and = 6); M = 36 yrs; input and milieu not reported; correctly doubled the number
SCED(MP across high school (n = teaching strategies; Individual; Face-to- implemented: of communicative
participants) 1) and post high book reading with Face increased from 0% turns from baseline
school(n = 5) researcher selected at baseline to 90% to intervention,
books or higher across all generalization and
Children: N = 6; intervention, maintenance. All
M = 74 months; generalization and increased number of
DS & CP maintenance semantic concepts
sessions expressed.

277
 APPENDICES

Authors, Research Participants: Training Outcomes

date and design Caregiver and
country Child variables Type of AAC Delivery: trainer; Caregiver(s) Child(ren)
implemented; training setting;
Skill/strategy group/individual;
trained; Routine online/face-to-
targeted face/self-study

USA
12. Nunes & SCED (MB N = 1: mother; Aided; Augmented Doctoral student ; Frequency of use Frequency of child
Hanline, across activities) 30 yrs; high input, output, Home; Individual of four strategies: communication
(2007) school milieu teaching Face-to-Face. Environmental turns increased.
USA strategies and arrangement and Most turns were
Child: N = 1; provide a means of AAC modelling non-imitative and
54 months; ASD communication in increased. Mands were accomplished
the activity; play and physical with aided AAC
and care routines guidance for the rather than
selected by the child to use AAC verbal/vocal modes
researcher did not increase. or manual
signs/gestures.

13. Olive, SCED (MP N=1: mother; post Aided; Augmented Graduate research Correct Challenging
Lang & across activities) high school output strategies; 4 assistant; Home, implementation behaviour reduced
Davis, leisure activities Individual; face-to- (95.9% ) of FCT after the intervention
(2007) Child: N = 1; selected by mother: face and self-study strategy during was implemented.
USA 48 months; ASD book reading, art, intervention. Attention requests
memory, puzzles Parent rated FCT increased in first 2
as acceptable activities after the
278
 APPENDICES

Authors, Research Participants: Training Outcomes

date and design Caregiver and
country Child variables Type of AAC Delivery: trainer; Caregiver(s) Child(ren)
implemented; training setting;
Skill/strategy group/individual;
trained; Routine online/face-to-
targeted face/self-study
before and after introduction of the
training and intervention, and
increased her generalized to other
ratings of its 2 activities post-
effectiveness post- intervention.
training
14. Park, SCED (Changing N = 3: mother (n Aided; augmented Researcher; PECS Phase 1-3 Independent picture
Alber- criterion design) = 3); M=34 yrs.; output strategies, Home; Individual, procedures exchanges increased
Morgan & high school (n = milieu teaching Face-to-Face implemented from 0 at baseline to
Cannella- 1), strategies and correctly on 65% - 100% during
Malone, post high school provide a means of average 99.6% of Phase 3B and were
(2011) (n = 2) communication in the time. maintained 1 month
USA the activity; Acceptability of post-training at 97.5-
Children: N = 3; requests of intervention was 100%.
M = 30 months; preferred items rated highly
ASD (average of 4.97
on the 5-point
scale).
15. Romski, Randomized N = 62: father (n Aided; augmented Six female Procedural fidelity AC-I and AC-O
Sevcik, controlled trial = 4), mother (n = input, augmented interventionists; Lab of strategy groups made more
Adamson, (with 3 treatment 58); M = 37 yrs.; output, milieu and Home implementation expressive
Cheslock, groups) high school (n = teaching strategies (18 sessions in Lab, was high for vocabulary gains,
Smith, 6) and post high and provide a 6 sessions in the parent-supported used more spoken
Barker, & school (n = 56) means of home); and parent-led words, and
Bakeman, Children: N = 62; communication in Individual; sessions (Kappa’s improved their TTR
(2010) M = 30 months; the activity; play, Face-to-face of 0.91-0.94). and intelligibility
USA Genetic book reading and rating more than the
syndromes, snack SC group. AC-O
seizure disorders, group used more

279
 APPENDICES

Authors, Research Participants: Training Outcomes

date and design Caregiver and
country Child variables Type of AAC Delivery: trainer; Caregiver(s) Child(ren)
implemented; training setting;
Skill/strategy group/individual;
trained; Routine online/face-to-
targeted face/self-study
CP, unknown augmented words
diagnoses that AC-I group.
16. Romski, Randomized N = 53: faither (n As for Romski et al As for Romski et al PPOLD measures: None reported
Sevcik, controlled trial = 4), mother (n = (2010) (2010) Parents from all
Adamson, (with 3 treatment 49); M = 37 yrs.; three groups
Smith, groups) high school (n= perceived
Cheslock & 6), themselves as
Bakeman, post high school more successful in
(2011) (n = 47) influencing their
USA child’s language
Children: N = 53; development post
M = 30 months; intervention, but
Genetic parents in the AC-I
syndromes, and AC-O groups
seizure disorders, showed a higher
CP, unknown increase. There
diagnoses was a decrease in
perceived
difficulty for AC-I
and ACO groups
but increase for SC
group. There was
an increased rating
of technology as
helpful for all three
groups, with the
highest increase
for AC-O group.

280
 APPENDICES

Authors, Research Participants: Training Outcomes

date and design Caregiver and
country Child variables Type of AAC Delivery: trainer; Caregiver(s) Child(ren)
implemented; training setting;
Skill/strategy group/individual;
trained; Routine online/face-to-
targeted face/self-study
17. Rosa- Mixed methods: N = 2: mother (n = Aided; Augmented Researcher; Percentage steps Percentage of
Lugo & Focus group (3 2); M = 39 yrs.; input, milieu Home; Individual; correctly communicative turns
Kent-Walsh culture experts, one high school (n = 2) teaching strategies Face-to-Face implemented: taken (in relation to
(2008) of which was and provide a Showed 100% opportunities created):
USA parent)and SCED Children: N = 2; M means of PND from Showed to 100% PND
(MPD across = 81months; communication in baseline to from baseline to
participants) Cystichygroma & the activity; Book instruction; and instruction.
DD reading 91% PND for Collateral data shows
maintenance. an increase in semantic
concepts produced
(PND=100%) from
baseline to instruction.

18. Senner, Quasi-experimental N = 4: mother (n = Aided; Augmented Researchers and Percentage of The number of unique
Post, Baud, Pre-posttest 4); post high school input, milieu student clinicians; modelled words independently
Patterson, Children: N = 4; teaching strategies University clinic; utterances (i.e. produced on SGD
Bolin, Lopez M = 82 months; and provide a Individual/group utterances increased but not
& Williams, NDD and means of sessions; accompanied by significantly.
(2019) VF paralysis with communication in Face-to-Face aided input)
USA tracheostomy the activity; significantly
core leisure increased from pre
activities to post-test.
Parents found the
training useful and
saw changes in
their children.

281
 APPENDICES

Authors, Research Participants: Training Outcomes

date and design Caregiver and
country Child variables Type of AAC Delivery: trainer; Caregiver(s) Child(ren)
implemented; training setting;
Skill/strategy group/individual;
trained; Routine online/face-to-
targeted face/self-study
19. Sigafoos, Case report N=1; mother Aided; Augmented Researcher; None reported Frequency of
et al., (2004) Children: N = 1; output, milieu University cafeteria independent requests
USA M = 144 months; teaching strategies and student meeting using an SGD (in
DD and seizure and provide a area, with feedback response to an
disorder means of in the Home; opportunity created)
communication in Individual; Face-to- increased from 0 at
the activity; Face and telephonic baseline to 100%
Snack and leisure during the university
activities training sessions and
generalized to the
home activities.

20. Starble, Case report Parents: (mother Aided; Augmented Researcher; High satisfaction rating None reported
Hutchins, and father); M = input, milieu teaching Home; Individual, of relevance
Favro, 38yrs; post high strategies and provide Face-to-Face and appropriacy of
Prelock & school a means of training, customization’
Bitner, communication in the SLPs' sensitivity and
(2005) Children: N = 1; 54 activity; knowledge; scores were
USA months; Parent-identified lower for the comfort o
CP activities using the device

21. Tait, SCED (MP N = 6: mother (n = Both (aided and Researcher; Home; The number of The number of original
Sigafoos, across 6); other details unaided); Individual, Face-to-Face times strategy prelinguistic
Woodyatt, behaviours) were not reported augmented input, was correctly behaviours decreased
O’Reilly, & augmented output, implemented increased The number
Lancioni, Children: N = 6; milieu teaching from baseline to of target replacement
(2004) M = 30 months strategies and intervention. communication
Australia SQ CP with provide a means of behaviours generally
epilepsy, mild communication in increased

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Authors, Research Participants: Training Outcomes

date and design Caregiver and
country Child variables Type of AAC Delivery: trainer; Caregiver(s) Child(ren)
implemented; training setting;
Skill/strategy group/individual;
trained; Routine online/face-to-
targeted face/self-study
hearing impairment, the activity; play,
mild vision mealtime, social
impairment, and
cortical visual
impairment, and
epilepsy

Note. PPD = Profound phonological process disorder, VCFS = Velocardiofacial Syndrome (also known as DiGeorge Syndrome), VPI = Velopharyngeal
Insufficiency, CAS = Childhood apraxia of speech, CP = Cerebral Palsy, ASD = Autism Spectrum disorders, ID = Intellectual
disabilities, DS = Down Syndrome, DD = Developmental disorders/disabilities, VF = Vocal Fold, SQ = Spastic Quadriplegia AC-O =
Augmented communic–tion - output, AC-I = Augmented communic–tion - input, SC = Spoken communication; ENGs = Enhanced
natural gestures, RAACS = The Responsive Augmentative and Alternative Communication Style Scale, CP-A = Communication
profile (Adapted), PND = Percentage of Nonoverlapping Data, IRD = Improvement Rate Difference, NAP = Nonoverlap of All Pairs,
FCT = Functional Communication Training. TTR = type token ratio
a
An additional caregiver participated in the focus group that preceded the training. b Augmented input strategies are used when the
communication partner models the use of the AAC strategy, for example by supplementing verbal speech with a manual sign or
pointing to a picture symbol. c Milieu teaching involves teaching communication skills within the natural environment, using strategies
such as mands, expectant delay, and environmental arrangements d Augmented output refers to prompting the child to use the AAC
modality. e Responsivity refers to parent communicative behaviors that include contingent responding to a child’s communication
attempts and initiation. f Provide a means of communication in the activity (using AAC) which include offering the child choices,
interrupted chain strategy and etc.

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APPENDIX D
D1 Cultural Stakeholder Interviews Participant Information Letter (English)

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D2 Cultural Stakeholder Interviews Participant Consent form (online English )

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D3 Cultural Stakeholder Interviews Participant Information Letter (Tshivenda)

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APPENDICES

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D4 Cultural Stakeholder Interviews Participant Consent form (online Tshivenda)

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D5 Cultural Stakeholder Inter–iews - Interview Schedule (English)

ENGLISH INTERVIEW SCHEDULE

Hello! My name is Vuledzani Ndanganeni (Madima). Thank you for volunteering to take
part in this interview. You have been asked to participate as your point of view is important to this
study. I realize you are busy and I appreciate you making time to participate. This interview is
intended to understand the beliefs and practices of Vhavenda parents regarding communication
interaction between parents and young children. I also want to understand cultural beliefs about
children with a communication disability, and how some of the intervention strategies may be
viewed by parents. The interview will take 60-90 minutes. It’s important that I record it and I
hereby request your permission to audio record the interview to facilitate data analysis. Do you
give me permission to record the interview? (Participant responds)
I will be recording the interview in order to be able to transcribe what is said accurately. I
would like to assure you that the discussion will be confidential. The recordings will be uploaded
onto a cloud and kept safely in a password protected computer. The transcription of the interview
will not contain any information that would link you to specific statements. The transcribed
interviews will be kept for 15 years at the University of Pretoria Centre for Augmentative and
Alternative Communication. If there are any questions that you do not wish to answer, you may
refrain from doing so. However, I will be grateful if you contributed to all the questions. Please
let me know when you would like to take a 5-minute comfort break so that we can pause and take
a break during the interview.
“Some of the questions are based on the videos that were sent to you. The first few
questions are aimed at understanding typical parent-child communication interactions.”
INTERVIEW QUESTIONS
1.1. In a typical Vhavenda family, who would be likely to communicate or speak
with a child aged 6 years or younger? Who would communicate the most to the
child?

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INTERVIEW QUESTIONS
1.2. What activities do parents and children aged 6 or younger usually engage in
during the day?
- During which activities do adults and children typically talk?
- During which ones would it be inappropriate or unusual to talk? What may be
the reasons?
1.3. Is it important for parents to speak to young children?
Follow up: Why is it important/not important? (this may already give an
idea as to the purpose? May not need to ask the next question?)
Probe: For what purpose would parents interact or communicate with a
child aged 6 or younger? (if participants struggle, give examples: parents would
want to teach children. they could teach how to communicate or behave or morals
or values).

1.4. Is it important for young children to talk to their parents?

Follow up: Why is it important/not important?
Probe: What is the purpose of young children speaking to parents?
1.5. When parents and children interact during (name activity that respondent
described as communication rich), how would this usually happen? For example,
where would the child be positioned in relation to the parent? Would the child
make eye contact? What kind of things would the parent say, and what kind of
things would the child say? Who would start talking first and who would answer?
1.6. What other forms of communication (besides speech) are accepted? Please
provide examples of these methods and what messages may be communicated
with these methods.

1.7. What cultural or traditional beliefs do Vhavenda hold regarding

communication disability in children? (What are their perceptions of
communication disabilities?)
1.8. Would a parent of a child with a communication disability usually seek help
or intervention for their child?
1.9. What kind of help would they seek?
1.10. What would they expect from….when seeking his/her help?
1.11. You have already told me how parents and young children without
disabilities typically interact. In what way may these aspects be different if a child
has a severe communication disability? (prompt on partners, activities, purposes,
roles)
3.1. For my research project, I am planning to train parents on three specific
aspects. The first is called responsiveness: This means a parent expects a child to
communicate and reacts to the child’s behaviour as if the child is communicating
or speaking. So, for example, if the child points to something the parent will give
it to the child, as if the child asked for it. Responsiveness also means that the
parent pays attention to what the child is looking at or doing, and comments on it.
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INTERVIEW QUESTIONS
The parent may also imitate what the child is doing. In the video I sent you, you
could see that the child focused their attention on the doll’s tummy. The adult sees
that the child looks at the doll’s tummy and the parent says tummy. The child then
lifts the doll and pa–s it - the adult responds by saying /hug- big hug/ while patting
her own doll. The child points to the side with the cot and the adult responds by
turning to the cot and taking out a doll. She reacts to the pointing as if the child
asked something.
- Would teaching parents to act in this way be culturally appropriate in your
opinion?
- If not, could it be changed to make it more so?
- Is there anything I should be aware of during this process to make sure it is
acceptable to parents?
3.2.The next thing I would like to teach parents to do is to give their child
opportunities to communicate. This means that the parent can encourage the child
to communicate by asking a question, letting the child choose between things or
by arranging the environment in such a way that the child is tempted to ask for
something. For example, the parent can give the child a little bit of food, like a
small piece of a biscuit, or fruit and then not giving the child more until the child
asks. Another example is putting something the child really wants where the child
can see but not reach it. For example, some food can be in a see-through
container that is tightly closed. In the second video, I sent you, the adult gives the
child a chocolate. The adult then closes and hides the chocolate packet. The child
comes closer to the adult and the adult waits for a communicative attempt. The
child the says /chokie please/, the adult gives the child another piece of chocolate.
In the third video, the adult shows the child a banana and an apple and asks the
child which one she wants. The child grabs the apple and says /aah/

- Would teaching parents to act in this way be culturally appropriate in your

opinion?
- If not, could it be changed to make it more so?
- Is there anything I should be aware of during this process to make sure it is
acceptable to parents?

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INTERVIEW QUESTIONS
3.3. The last strategy involves pointing to pictures while speaking. Parents will be
given picture boards like the one I sent you. I will teach them to point to pictures
as they are talking to the child. In this way they can teach the child to also point to
pictures. In the video: On this video you can see an adult talking and pointing to
the relevant pictures on a picture board. For example, the adult said “today we
worked” and she pointed to the picture of work. When she said “we were all done
with work, we go to play with toys” and she pointed to all done, go, play and toys
on the picture board. In the same way, the mealtime board can be used by both the
parent and the child. The parent might signal the end of the mealtime activity by
telling the child the tummy is full. The child can show “more” when they want
more food. The adult can request the child to open the mouth by saying and
pointing to picture showing ‘open mouth’

- Would teaching parents to act in this way be culturally appropriate in your

opinion?
- If not, could it be changed to make it more so?
- Is there anything I should be aware of during this process to make sure it is
acceptable to parents?
4. Would it be acceptable for me as a speech therapist to train parents of young
children with communication disabilities to communicate more effectively with
their children? What aspects should I be aware of in order to ensure that the
training will be respectful and acceptable to parents?
- Is there anything you would like to add that you think will be useful to the
study?
- Do you have any questions you would like to ask me before we conclude
the interview?

Thank you for sharing your time, knowledge, expertise and experiences with me and
contributing towards the study. I will send the analysed interview results for you to check if it
represents your views. I really appreciate your input in this regard. Have a good (evening,
afternoon or morning further). Aa!!”

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D6 Cultural Stakeholder Inter–iews - Interview Schedule (Tshivenda)

TSUMBAVHUYO YA NYAMBEDZANO – VHAṰALUKANYI VHA MVELELE
Aa! Dzina ḽanga ndi name Vuledzani Ndanganeni (Madima). Ndi a livhuwa vho tenda
u shela mulenzhe kha ino nyambedzano. Vho humbelwa uri vha shele mulenzhe kha ino
nyambedzano ngauri vhupfiwa havho ndi ha ndeme kha ino ngudo. Ndi a zwi pfesesa uri
vha muthu ane a dzula o fareledzwa nga mishumo minzhi, ngauralo, ndi a livhuwa vho
ḓiṋea tshifhinga tsha u shela mulenzhe kha ino nyambedzano. Ndivho ya ino
nyambedzano ndi u ṱoḓa u pfesesa maitele a sialala na a mvelele ane tevhedzwa nga
vhaleli vha Vhavenḓa o livhanywa na vhudavhidzani vhukati ha vhaleli vha vhana vho
holefhalaho na vhana vhone vhaṋe, khathihi na vhutendatenda malugana na vhana vhaṋe
vha vha na vhuholefhali ha vhudavhidzani. Nyambedzano ino yo anganyelwa u dzhia
mithethe ya fuiṋa u ya kha ya furathi. Ndi zwa ndeme uri ndi rekhode nyambedzano
yashu. Ngauralo, ndi humbela thendelo yavho uri ndi rekhode sa vhunga makumedzwa
avho a tshi ḓo nthusa kha tsaukanyo ya mafhungo o kuvhanganywaho.
(Mufhinduli u a fhindula)
TSHIDZUMBE NA U SA BULWA MADZINA: “Ndi ḓo rekhoda nyambedzano yashu
hu u itela uri ndi kone u ṅwalulula maambiwa avho o tou ralo. Ndi tama u vha
fulufhedzisa uri nyambezano Iashu i ḓo vha ya tshidzumbe. Zwo rekhodiwaho, zwi ḓo
vhulungwa kha khomphyutha hune zwa ḓo tsireledzwa nga nḓila ine zwi nga si ḓo
swikelelwa nga nnyi na nnyi. Muṅwalululo wa nyambedzano a u nga ḓo vha na mafhungo
ane a ḓo ita uri vha ṱumanywe na zwe vha amba. Muṅwalululo wa nyambedzano yashu u
ḓo vhulungwa University of Pretoria Centre for Augmentative and Alternative
Communication lwa miṅwaha ya fumiṱhanu. Arali hu na mbudziso dzine vha pfa vha sa
ṱoḓi u dzi fhindula, vho tendelwa u ḓibvisa kha u fhindula. Fhe296an wanndi nga livhuwa
arali vha shela mulenzhe kha u fhindulwa ha mbudziso dzoṱhe.” “Ndi humbela uri vha
mmbudze arali vha tshi ṱoḓa tshikhala tsha u awela lwa mithethe miṱanu uri ri kone u
ima, vha awele phanḓa ha musi nyambIdzano i tshi nga bvela phanḓa.”

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“Dziṅwe mbudziso dzo ḓisendeka kha ṱhalutshedzo na tsumbedzo dze vha rumelwa.
Ndivho ya mbudziso dza u ranga dzi si gathi ndi u ṱoḓa u pfesesa vhudavhidzani ho
ḓoweleaho vhukati ha vhaleli na vhana.”
Mbudziso dza Nyambedzano
Kha muṱa wo ḓoweleaho wa Vhavenḓa, ndi nnyi ane a nga anzela u davhidzana297an
wan amba na ṅwana wa miṅwaha ya rathi kana ya fhasi ha ya rathi? Ndi nnyi ane a nga
ambesa na ṅwana?

Ndi nḓowenḓowe dzifhio dzine vhaleli vha vhana vha miṅwaha y297an whi na ya fhasi
ha ya rathi vha anzela u ḓidzhenisa khadzo musi vha tshi khou lela vhana?
Kha nḓowenḓowe dzenedzo dza ḓuvha ḽiṅwe na ḽiṅwe, ndi dzifhio dzine dzi nga 297an
waa sa dzo pfumaho nga vhudavhidzani?
Ndi kha nzulele dzifhio dza nḓowenḓowe hune vhathu vhahulwane na vhana vha
anzela u amba vhoṱhe? Ndi kha nzulele dzifhio dza nḓowenḓowe hune vhudavhidzani
vhu nga iledzwa kana hune vhudavhidzani a ho ngo ḓowelea? Ndi ngani zwo ralo?

Ndi ndivho ifhio ine vhaleli vha vhana vha ṱoḓa u i swikelela nga u davhidzana na
ṅwana wa miṅwaha ya rathi kana wa miṅwaha ya fhasi ha ya rathi? Ndi ngani zwi zwa
297an wan amba na ṅwana? Ndi ndivho ifhio ine ya ṱoḓa u swikelelwa musi vhana
vhaṱuku v297an wan amba na vhaleli vhavho? Zwi vhonwa zwi zwa ndeme musi
ṅwana a tshi ita ngauralo?
Kha vhudavhidzani na ṅwana, mushumo wa muleli ndi ufhio? Mushumo wa ṅwana
wone ndi ufhio? (Ho lavhelelwa zwifhio kha ṅwana?)
Ndi vhutendatenda vhufhio ho livhanywaho na mvelele ya Tshivenḓa kana sialala ḽa
Tshivenḓa vhune Vhavenḓa vha vhu tevhedza musi zwi tshi ḓa kha u davhidzana na
vhana vhane vha vha na vhuholefhali ha vhudavhidzani? (Ndi dzifhio mbonalo dzine
Vhavenḓa vha vha nadzo malugana na vhuholefhali ha vhudavhidzani?)

Ndi dzifhio dziṅwe nḓila dza vhudavhidzani (nga nnḓa ha muambo/u amba) dzo
ṱanganedzwaho? Ndi humbela uri vha ṋee tsumbo dza nḓila dzenedzi khathihi na zwine
dza amba zwone.

Vho no mmbudza uri vhaleli vha vhana vha anzela u davhidzana hani na vh297an wha
si na vhuholefhali. Hu nga vha na phambano kha kudavhidzanele na vhana arali vho
vha vha tshi khou davhidzana na ṅwana ane a vha na vhuhofhelani ha vhudavhidzani?
(vha kwamevho na vhatikedzi, nḓowenḓowe, zwipikwa na dziṅwe nyito)

Muleli wa ṅwana ane a vha na vhuhofhelali ha vhudavhidzani u na hune a nga ṱoḓa

thuso kana vhudzheneleli ha vhaṅwe vhathu uri vhudavhidzani na ṅwana vhu
konadzee? Ndi dzifhio ndavhelelo dzine dza livhanywa na u dzhenelela ha vhathusi
kha uri vhudavhidzani na ṅwana onoyo vhu konadzee?

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Mbudziso dza Nyambedzano

Hu na maitele ane a dzhiiwa sa o ḓoweleaho musi hu tshi khou aluswa ṅwana wa
miṅwaha ya fhasi ha ya rathi, sa u mu beba muṱanani? Maṅwe maitele a ngaho enea
ane a dzhiiwa sa a ḓoweleaho kha vhana vha miṅwaha ya fhasi ha ya rathi ndi afhio?
(Maitele aya o vha a tshi ḓo ṱanganedzea kha ṅwana ane a vha na CCN na
vhuholefhali?
Ndi tama u ḓivha mihumbulo yavho malugana na u ṱanganedzea ha zwi tevhelaho kha
mvelele ya havho: U fhindula, nḓisedzo ya zwikhala zwa u amba musi hu tshi khou
davhidzaniwa. (ṱhalutshedzo dzi ḓo ṋewa)

Kha ṱhoḓisiso yanga, ndo anganya u pfumbudza vhaṱhogomeli vha vhana ndo livhanya
u pfumbudza honoho na zwiteṅwa zwiraru.

U fhindula ndi musi muleli a tshi lavhelelwa u dzhiela nzhele ndingedzo dza
vhudavhidzani dzine ṅwana a dzi shumisa u davhidzana nga u mu fhindula. Muleli a
nga fhindula na u ṱalusa zwine ṅwana a khou lingedza u amba nga u mu vhudzisa
mbudziso, u mu fhindula na u ṋea ṅwana zwine a nga vha a tshi khou ṱoḓa zwone
ngauri muleli a vha o kona u ṱalusa ndingedzo dza vhudavhidzani dzine ṅwana a dzi
shumisa. Ndi ṱoḓa u vha pfumbudza uri vha kone u dzhiela nzhele ndingedzo dza
vhudavhidzani dza ṅwana (sa tsumbo, arali ṅwana a lila…). Ndi ṱoḓa hafhu u vha
pfumbudza u dzhiela nzhele nḓila dzenedzo na uri vha nga dzi fhindula hani.
(Tsumbedzo ya uri izwi zwi shuma hani?) U ya nga kuvhonele kwavho, maitele aya a
nga ṱanganedzea kha mvelele ya havho? Arali phindulo hu ‘hai’, zwi a konadzea uri
maitele aya a shandukiswe lune a anana na maitele a mvelele ya havho? Hu na zwine
nda tea u zwi dzhiela nzhele kha u ita uri u pfumbudzwa ho raliho hu ṱanganedzee kha
vhaleli?

Nḓisedzo ya zwikhala zwa vhudavhidzani: muleli a nga vhudzisa mbudziso dzine dza
fhindulwa nga ‘Ehe/Hai’, mbudziso dzine dza tendela vhudodombedzi, kana u ṋea
ṅwana tshikhala tsha u nanga. Muleli u lindela lwa mithethenyana miraru u ya kha
miṱanu hu u itela uri ṅwana a vhe na tshikhala tsha u fhindula, a konaha u fhindula
zwine ṅwana a khou amba nga hazwo, a khwaṱhisedza zwine ṅwana a amba kana a ṋea
ṅwana tshikhala tsha u nanga. Arali ṅwana a sa fhindula, muleli a nga lingedza u sika
dziṅwe nḓila dzine dzi nga ṱuṱuwedza ṅwana u amba, sa tsumbo, nga u fara tshanḓa
tsha ṅwana a tshi khou mu thusa u sumba na u nanga zwine a ṱoḓa.

U ya nga ha kuvhonele kwavho, maitele o raliho a nga ṱanganedzwa kha mvelele ya

havho? Arali phindulo hu ‘hai’, zwi a konadzea uri maitele enea a shandukiswe lune a
swika hune a anana na mvelele ya havho? Hu na zwine nda tea u zwi dzhiela nzhele hu
u itela uri maitele enea a ṱanganedzee kha vhaleli?

Thusedzi ya kushumisele kwa luambo i katela u shumiswa ha tshifanyiso kana u

davhidzana hu tshi khou shumiswa ḓaba ḽa zwifanyiso ḽi fanaho na ḽe nda vha rumela.
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Mbudziso dza Nyambedzano

Muleli u sumba zwiga kha ḓaba ḽa nḓowenḓowe zwenezwo musi a ts299an wan amba
na ṅwana. Muleli u sumba tshiga tshine tsha ombedzela ipfi (sa tsumbo, Muleli: “ḽisani
mupopi mukapu”-muleli a mbo ḓi sumba zwiga zwo imelaho ipfi ḽi ombedzelwaho).

“Hu na zwiṅwe zwine vha ṱoḓa u engedza zwine vha vhona zwi tshi nga vha zwa ndeme
kha ino ṱhoḓisiso? Hu na mbudziso dzine vha ṱoḓa u mmbudzisa phanḓa ha musi ri tshi
nga khunyeledza nyambedzano yashu? Ndi a livhuwa u kovhelwa tshifhinga tshavho,
nḓivho, tshenzhemo khathihi na u shela havho mulenzhe kha ino ngudo. Ndi ḓo vha
rumela muṅwalululo wa nyambedzano yashu uri vha khwaṱhisedze uri ndi makumedzwa
avho. Ndi ḓo vha kovhela mawanwa a ṱhoḓisiso, arali vha tshi nga zwi takalela. Vha nga
nnḓivhadza nga u tou shumisa mulaedza wa luṱingo arali vha tshi nga zwi takalela u
kovhelwa mawanwa. Ngauralo, ndi a livhuwa u shela havho mulenzhe u swika zwino.
Kha ḽi vhe ḓuvha ḽavhudi (vhusiku havhuḓi, masiari/mathabama avhuḓi kana
matsheloni/maṱavhelo avhuḓi). Aa!”

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D7 Interview Material - Videos

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D8 Interview Material-Communication Board

303
 D9 Synthesized Member Checking (Email)

Dear Stakeholder

I recently interviewed you about interactions for young children under the age of six years
in the Vhavenda culture. Thank you for having taken the time to participate in the
interviews, I learnt a lot of things and found interesting data. I interviewed about 10
people during that period.

As I mentioned to you before starting the interview, I am now sending you a summary
of the results (see document attached). In order to make sure I did not miss anything, I
want to ask you to please read through the summary. If you think I missed something or
did not interpret something correctly, please let me know. You are welcome to provide
feedback in the document, or send me a text or an email. If you prefer you can also let me
know and I will call you so that we can discuss any feedback you have.

I would be most grateful for your response by Thursday 19 .11.2020.

Kind Regards

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 D10 Synthesized Member Checking Summary
Summary of results obtained in cultural stakeholders’ interviews

I summarised the responses under four main categories. The first is about how children
interact, the second about communication disabilities, the third about the training I want
to do and the fourth is about how things have changed in the Vhavenda culture over time.

How young children without disabilities interact

When asked about who would typically interact with a child six years or younger,
stakeholders mentioned that the children will interact with the mother, grandmother,
parents and grandparents. However, if the mother is young, the grandmother and elderly
women assume the role that the mother would take. They do this to teach the mother how
it is done. Other family members such as siblings and elderly females (i.e. the aunt,
cousin) were also mentioned. Furthermore, due to the changing times and the lives of
primary caregivers, teachers at creche and the helper may also be important
communication partners of the child.

Children and caregivers typically do a number of activities together. When caregivers go

on their daily chores (i.e., sweeping, making the bed, cleaning) children under six years
are involved as their caregivers are teaching them to do the chores and also talk to them
during the chores to stimulate language. Other activities included daily child routines such
as bathing, brushing teeth, eating, playing and some of the activities that people in rural
areas engage in during harvesting season. Children aged 6 or younger play with other
children but also play with caregivers, especially the younger children. Caregivers and
children communicate with each other during most of these activities. However, some
participants mentioned that talking is prohibited when children are eating because of
safety reasons (to prevent choking), respect for the cook and also it is tradition not to eat
and talk.

It was reported that it is important for children to talk to caregivers and for caregivers to
talk to children in the Vhavenda culture. Children will communicate to caregivers for
various reasons such as talk about their plans for the future or share what has happened
to them. This is especially important if the child has had a bad experience. Children will
also express when they need or want something. By talking to caregivers, children can
improve their speech- and language skills and form relationships with others. Caregivers
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communicate with children in order to comment, answer the children’s questions, give
children instructions, ask the children questions, and teach the children.

When asked about who is allowed to start the conversation, participants indicated that
both caregivers or children can start the conversation (initiate interaction).

Although some participants mentioned that amongst older individuals eye contact is not
always appropriate, it was reported that young children may look a parent in the eye.

It was reported that a variety of communication methods (not only speech) are acceptable
and important in the Vhavenda culture. Most if not all of the participants reported the use
of the look or eye that caregivers use to reprimand, discipline or indicate dissatisfaction
with the child’s behaviour in the presence of visitors. They furthermore use this to correct
child’s behaviour. Other methods included touch (i.e. a smack), pointing, gestures,
vocalisations and using mouthing (i.e. silently moving your mouth to speak without suing
your voice), demonstrations and the use of pictures or drawings.

Communication disability

Vhavenda often believe that communication disability occurs as result of witchcraft, curse
or parents breaking taboos. Other beliefs about the cause of communication disability
include: other people could have caused it, hereditary, use of ‘muti’ and that it is the will
of the ancestor. One of the participants reported that parents are judged in their respective
communities. Some reported that not everyone believes that witchcraft causes a
communication disability.

When asked about the help that parents seek for their children with communication
disabilities, it was reported that some will seek help from the traditional healers, prophets
or pastors. When parents seek such help, the parent often expects a miraculous complete
healing. Others parents are seeking help from healthcare practitioners such as doctors,
speech language therapists and physiotherapists. When parents seek such help they
typically do not expect a miracle cure, but they do expect their child to improve, and
maybe learn how to speak, to communicate, for others to understand the child and for the
child to grow up to be more independent and responsible. Parents expect healthcare
professionals to help them or teach them how to communicate with their kids. Most
participants reported that expectations of help seeking are that the children will talk.

306
Other forms of help that parents sought were help to get the care dependency grant, or
help for their children to get an education. Parents were also offered help through
community empowerment programmes. These programmes were highlighted as helping
parents to make their own choices and become empowered.

In general, all caregivers expect positive changes when seeking help regardless of where
they go for help.

One participant mentioned that, even when parents wait for a miracle, they should take
other action in the meantime, rather than doing nothing. It was also reported that some
caregivers do not seek help because they hide their children. Some believe that nothing
can be done to help the child while others believe the child will improve without
intervention.

When asked if the way in which caregivers and children interact differs when the child
has a communication disability, compared to the child not having a disability, there were
various opinions. In general, participants felt that the interactions were the same, and that
the children with communication disabilities did the same activities. However, it was
reported that children with communication disability may be more passive in interaction,
and that they require more patience and understanding. They were also reported to be
slower.

Comments on the training I want to do

During the interview, I asked you and the other participants if the strategies I want to
train caregivers to use are appropriate in the Vhavenda culture. These strategies are: 1)
responding to the child, 2) giving the child opportunities to communicate, and 3) pointing
to pictures while speaking. You will remember that I asked you to watch some videos and
comment on the skills and the way in which they were trained.

Although most participants mentioned that these strategies are appropriate, there were
some suggestions to amend the training to be more culturally appropriate. One participant
mentioned that in the traditional Vhavenda culture, the child is not at the centre for
everyone. This should be kept in mind when responding to the child. Participants also
commented on the material that was used in the videos shown to them. When creating
communication opportunities (choice making activity), it was suggested that the

307
researcher uses items and foods that are available to the child in their context. Pointing to
pictures while talking was widely accepted with the following reasons: child knows what
is being said, child learns effectively how to point and talk, child will remember, t’e
child's mind will function effectively with pictures, aids quick understanding of message
and quickens the learning process.

Participants in general felt that the caregivers will accept the strategies if they help the
child and improve their quality of life. When training caregivers, the researcher must
establish if the caregivers are interested in the training, find out if they are committed,
and establish a good rapport. She must be friendly. The researcher should establish what
parents have already been doing and build on it. The researcher must acknowledge that
parents have skills and expertise. The researcher must be respectful of parents’ practices
and accommodate everyone regardless of their beliefs and practices. The researcher must
use the caregiver’s l–nguage - simple terms that everyone can understand. She should use
materials that are culturally acceptable.

Changes in the Vhavenda culture over time

Some participants mentioned that there have been changes in the Vhavenda culture over
time. Some mentioned that the way in which children are raised and in which they interact
has changed over time. For example, grandparents may not be living with the family and
therefore play less of a role in childcare. On the other hand, paid helpers may play more
of a role. Parents nowadays may also not allow their children out of sight as easily due to
concerns about safety. It was also mentioned that practices such as hiding children with
disabilities and beliefs about the cause of communication disabilities have changed over
time. Some of these changes were caused by changes in religious beliefs and levels of
formal education. It was mentioned that some of the training strategies may be better
accepted by parents who are ‘modern’.

308
 APPENDIX E
E1 Biographical Questionnaire

Participant ID: PA-

SECTION A: BIOGRAPHICAL INFORMATION

A1 Caregiver Information

What is your age? _________________

What is your gender? Female

Male
Other

Relationship with the child:________________________________

What is your highest qualification level?________________________________

What is your home language?________________________________________

Where do you attend Speech therapy?

Siloam Hospital
Tshilidzini Hospital
Donald Fraser Hospital
Musina Hospital
Louis Trichadt Memorial
Hospital

How often do you take your child for speech therapy?

Once a week
Once every two weeks
Once a month
Once every two months
Every 6 months
Once a year
When we have money

A2 Child Information

309
 What is your child's gender?
Female
Male

What is your child’s age?__________________________________

What is the diagnosis of your child?___________________________

A3 Fine Motor status

How does your child indicate what they want?

A4 Gross Motor status

How does your child move around?

A5 Visual status
Describe yo’r child's vision?

A6 Hearing status
Describe yo’r child's hearing skills.

Has yo’r child's hearing been tested ?

If yes, what were the results?

A7 Education information
Does your child attend any educational or child care setting?
Yes
No

If yes, please describe the setting

_____________________________________________________

SECTION B : COMMUNICATION

Does your child use spoken words to

B1 communicate?______________________________________

310
B2 If yes, How many spoken words does your child use to
communicate?_________________________

Does your child use different words to communicate? Describe:

_______________________________________________________

B3 How does your child communicate?

Gestures
Points to things
Vocalizations (sounds)
Jargon (talking in a language you don’t
understand/Baby language)
Unintelligible speech (unclear words)
Facial expressions (e.g., smiling)
Signs from sign language
Communication board or book with pictures
Speech Generating device (device that tals loud)
Eye pointing

B 4: How do you communicate with your child?

__________________________________________________________
__________________________________________________________

B 5 Does your child respond when you call their

name?
Yes
No
Sometimes

Please specify what happens: _____________________________________

B 6 Does your child understand when you talk to him?

Yes
No
Sometimes

Please specify ______________________________________________________

311
B7 Communication Functions
Which of the following communication functions does your child do and how well do they do it?
Less Most
Request help 0________1________2________3________4________5________6________7________8________9________10
Request objects 0________1________2________3________4________5________6________7________8________9________10
Protest 0________1________2________3________4________5________6________7________8________9________10
Confirm 0________1________2________3________4________5________6________7________8________9________10
Draw attention to his/herself
0________1________2________3________4________5________6________7________8________9________10
Get othe’ people's attention
0________1________2________3________4________5________6________7________8________9________10
Label items 0________1________2________3________4________5________6________7________8________9________10
Make choices 0________1________2________3________4________5________6________7________8________9________10
Indicate humour 0________1________2________3________4________5________6________7________8________9________10
Show interest in objects
0________1________2________3________4________5________6________7________8________9________10

B8 Frequency of Communication
How frequently does the child communicate with the following people?
Not at all Most of the time

Caregiver 0________1________2________3________4________5________6________7________8________9________10
Parent 0________1________2________3________4________5________6________7________8________9________10
Siblings 0________1________2________3________4________5________6________7________8________9________10
Peers 0________1________2________3________4________5________6________7________8________9________10
Unfamiliar people 0________1________2________3________4________5________6________7________8________9________10

312
 SECTION C : ACTIVITIES

C1 Activities that caregivers engage in with their child

Which communication rich activities do you and your child engage in? ( name 3)
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

How frequently do you and your child communicate in these activities ?

Less______________________________________________________________________________Most
1________2________3________4________5________6________7________8________9________10

C2 Activities Rating
Which activities would you say you and your child engage in the most? Rate the activities .
Less______________________________________________________________________________Most
Morning routine (waking up, brushing teeth and washing the face)
1________2________3________4________5________6________7________8________9________10
Mealtime (breakfast, Lunch)
1________2________3________4________5________6________7________8________9________10

Snack time (when the child wants water, juice, biscuits or simbas)

313
 1________2________3________4________5________6________7________8________9________10

Bath time
1________2________3________4________5________6________7________8________9________10
Dressing up
1________2________3________4________5________6________7________8________9________10
Which daytime activity do you interact in with your child?__________________________________________________
_________________________________________________________________________________________________
Examples : Daytime activities (playing with child, singing, reading, telling a story or etc)

C3 Which activities would you say are enjoyed by you and your child ?

Morning routine (waking up, brushing teeth and washing the face)
1________2________3________4________5________6________7________8________9________10
Mealtime (breakfast, lunch)
1________2________3________4________5________6________7________8________9________10
Snack time (when the child wants water, juice, biscuits or simbas)
1________2________3________4________5________6________7________8________9________10
Bath time
1________2________3________4________5________6________7________8________9________10
Dressing up
1________2________3________4________5________6________7________8________9________10

SECTION D: AUGMENTATIVE AND ALTERNATIVE COMMUNICATION

D 1 Awareness
314
 Have you heard of augmentative and alternative communication before ?
Yes, ive heard about it
No, I have never heard of it
Unsure

If the participant answers no to the question, give a definition of AAC.

AAC is ways other than speech that are used to enhance or repl“ce the”"normal" ways of communication. Others will write or type what they want to
say, use gestures, pictures, signs, gestures, devices and etc.

If yes, describe what you know: ____________________________________________________________

_____________________________________________________________________________________

Are you aware that AAC strategies help children and adults communicate better
where it is difficult?
Yes
No
Unsure
D2 Interests
D2.1 Do you think using AAC would benefit other children with CCN?
Yes
No

315
 Do you think the use of AAC will benefit your
child?
Yes
No

Are you interested in learning how to implement augmentative and alternative

communication?
Yes
No

D2.2 On a scale of 1 to 5 (1 being less interested and 5 being most interested), please rate
the following in the order of priority by crossing off the number.

I am interested in learning how to implement AAC during the following activities

with my child:

Morning routine (waking up, brushing teeth and washing the face)
1________2________3________4________5
Mealtime (breakfast, Lunch)
1________2________3________4________5
Snack time (when the child wants water, juice, biscuits or simbas)
1________2________3________4________5
Bath time
1________2________3________4________5
Dressing up/Undressing
1________2________3________4________5
Daytime activities (playing with child, singing, reading, telling a story or etc)
1________2________3________4________5

316
E2 Biographical Questionnaire Flash Cards

317
 APPENDIX F
Communication Matrix

318
 Pot

Car
Ball
Cup

Plate

Pants
Table

Spoon
Couch

TEST ITEMS
TRIAL ITEMS
The researcher introduces the
activity to the child

The researcher shows the child one

board at a time.

The researcher calls out the word

using the carrier“ phrase "show me
t” e ____"

The researcher makes sure the child

is focused on the communication
board.

The researcher makes sure the child

listens to the word by repeating the
APPENDIX G

target word twice.

The researcher waits 5-10 seconds

for the child to respond .

If the child points to an incorrect

picture, the researcher will ask the
G1 Picture Recognition and Representational Task Procedural script

child to look at the picture again to

find the target word

The researcher acknowledges t’ e

child's response by“ saying
"aha“ or hmm "

The researcher will close the session

by giving the child a sticker on the
319

forehead and also on the hand.

 Shirt
Soap

Chair
Blanket
Toothbrush

Phone (cell phone)

The researcher introduces the
activity to the child

The researcher shows the child one

board at a time.

The researcher calls out the word

using the carrier“ phrase "show me
t” e ____"

The researcher makes sure the child

is focused on the communication
board.

The researcher makes sure the child

listens to the word by repeating the
target word twice.

The researcher waits 5-10 seconds

for the child to respond .

If the child points to an incorrect

picture, the researcher will ask the
child to look at the picture again to
find the target word

The researcher acknowledges t’ e

child's response by“ saying
"aha“ or hmm "

The researcher will close the session

by giving the child a sticker on the
320

forehead and also on the hand.

G2 Picture Recognition and Representational Task

321
 G3 Picture Recognition and Representational Task Scoring Form

Participant ID: _______

Trial item 1 Couch

Trial item 2 Table

Trial item 3 Pot

Test item 1 Car

Test item 2 Ball

Test item 3 Cup

Test item 4 Plate

Test item 5 Spoon

Test item 6 Pants

Test item 7 Toothbrush

Test item 8 Soap

Test item 9 Phone (cell phone)

Test item 10 Blanket

Test item 11 Chair

Test item 12 Shirt

Correct items
Total number of items 12
Percentage of correct
items
%

322
 APPENDIX H
Visual Function Classification System

323
 APPENDIX I
I1 Mini- Manual Abilities Classification System

324
I2 Manual Abilities Classification System

325
 APPENDIX J
Materials for eliciting fine motor skills
Boy and Girl Peg Puzzles

Linking Stars Fine Motor Skills Puzzle Board

326
 APPENDIX K
Pre- Intervention Commitment Form
Muano/statement Hai/No Ee!/Yes
1. Ndi kho u nea thendelo mutodisisi ya u ri a
de mudini wa hashu.
I allow the researcher to come into our home
2.
Ndi khou nea muthodidisi thendelo ya u tola
nwana wanga na u mmbudzisa dzi
mbudziso.
I allow the researcher to screen my child and
also ask me questions.
3. Ndi do fhindula mmbudziso dzothe nga
ngoho
I will answer all the questions truthfully
4. Ndi do vhudzisa hune nda sa pfesese
I will ask questions where I do not
understand
5. Ndi do dzudzanya na mutodisisi maduvha
na tshifhinga zwo teaho uri ri ise phanda na
thodisiso heyi
I will provide the researcher with accurate
days and times
6. Ndi do divhadza mutodisisi hu tshe na
tshifhinga tshi no lingana awara dza 24 kana
duvha uri ri do vha ri siho.
I will inform the researcher with 24 hrs if I
will not be available
7. Ndi do shela mulenzhe kha u pfumbudziwa
lwa maduvha mavhili uya nga he zwa
talutshedziwa
I will participate in the training over 2 days
consecutively
8. Ndi do khwathisedza uri ndi vhe hone lwa
maduvha mavhili a u pfumbudziwa
I will be available for training over the 2
days
9. Ndi do shumisa tshomedzo dzothe dzine nda
do fhiwa dzone uya nga hune mutodisisi a
do vha o ntalutshedza ngaho.
I will use all the equipment and materials
that will be given to me as directed during in
the training.

327
 Muano/statement Hai/No Ee!/Yes
10 Ndi do vusuludza zwe nda pfumbudziwa
zwone khathihi na u vhudidzisa hune a
thongo pfesesa
I will refer back to the training booklets and
ask the researcher questions.
11 Ndi do shela mulenzhe kha ndowe ndowe
dzothe
I will participate in all the activities
12 Ndi do shela mulenzhe musi hu khou
dzhiiwa dzi vidiyo lwa maduvha mararu uya
kha matanu musi ri tshi thoma nga heino
ngudo.
I will participate in the 3-5 sessions for
when the researcher takes videos in the
beginning of the study.
13 Ndi do ita tshunwahaya dzothe dzine nda do
newa
I will do homework that the researcher gives
me
328an wananganwananga ri do vha hone
kha luta lwa vhuna musi mutodosisi a khou
foda nga vidiyo lwa maduvha matanu uya
kha a malo, nda dvha hafhu nda shela
mulenzhe kha dzinyambedzano.
I will avail myself and my child for the
researcher to take videos of the guided
practice sessions (5-8 sessions)
14 Ndi do shela mulenzhe kha luta lwa vhutanu
musi mutodosisi a khou foda nga vidiyo lwa
maduvha mararu uya kha matanu
mafhedziseloni a ngudo heina nga murahu
ha vhege 3.
I will avail myself and my child for the
researcher to take videos of the maintenance
sessions (3-5 sessions)
15 Ndi do isa phanda na u shumisa mbekanya
maitele musi ndi kho davhidzana na nwana
duvha linwe na linwe.
I will use the strategies taught during daily
activities

328
 APPENDIX L
L1 Tablet Training Script (English) and L2 Tablet Training Script (Tshivenda)

329
 APPENDIX M
Communication Boards (Activity Boards)

330
331
332
333
334
335
 APPENDIX N
Procedural fidelity Script – Baseline, Intervention and Maintenance Condition

Participant ID:

Date: Session:

Baseline, Intervention and Maintenance Done Not

conditions done

The researcher greets the participants

The researcher introduces herself

inf“rmally "Vuledzani is back aga”n
today"

The researcher instructs the caregiver they

must interact with the child how you
normally do in the activity they chose
before.

The researcher tells the caregiver that the

video will be taken for 15 minutes.

The researcher instructs the caregiver to

ignore the cameras and researcher as
much as possible.

The researcher removes remains in camera

view but not distracting the child

The researcher does not provide any

comments or prompts to the caregiver-
child dyad during the video

Total number “Done”

Total number of items 7

Percentage %

336
 APPENDIX O
O1 Day 1 Training Presentation (English)

For the complete set of training slides, please go to :

https://drive.google.com/file/d/1o6t_GwFN10H1ynOonGHmfBc4jEod5pE4/view?usp=shar
e_link

337
 O2 Day 1 Training Presentation (Tshivenda)

For the complete set of training slides, please go to :

https://drive.google.com/file/d/1o6t_GwFN10H1ynOonGHmfBc4jEod5pE4/view?usp=shar
e_link

338
O3 Training Materials - Communication Board example

339
 O4 Day 1 Training Procedural Fidelity Script
Participant ID:
Date:

Activity Yes No Comments

Setting up equipment

Greetings

Introductions

Handing caregiver
material

Scheduling of the day

Introduction to topics

Objectives explained

The researcher explains

what is expected of the
caregiver for homework
activities

The researcher explains

the reflection activity to
the caregiver

The researcher ends the

day by thanking the
caregivers

340
Communication Yes No Comments

The researcher
introduces the topic

The researcher defines

concepts

The researcher explains

the videos after showing
the caregiver

The researcher shows

caregivers artefacts
during training

The researcher asks

caregivers questions
throughout presentation

Caregivers are given

opportunities to ask
questions

The researcher facilitates

discussions with
caregivers

The researcher provides

caregivers with feedback

341
AAC Yes No Comments

The researcher
introduces the topic

The researcher defines

concepts

The researcher explains

the videos after
showing the caregiver

The researcher shows

caregivers artefacts
during training

The researcher asks

caregivers questions
throughout presentation

Caregivers are given

opportunities to ask
questions

The researcher
facilitates discussions
with caregivers

342
Aided language input Yes No Comments

The researcher
introduces the topic

The researcher defines

concepts

The researcher explains

the videos after
showing the caregiver

The researcher shows

caregivers artefacts
during training

The researcher asks

caregivers questions
throughout presentation

Caregivers are given

opportunities to ask
questions

The researcher
facilitates discussions
with caregivers

The researcher provides

caregivers with
feedback

The researcher explains

what is expected of the
caregiver during
activities

343
Contingent Yes No Comments
responding

The researcher
introduces the topic

The researcher defines

concepts

The researcher explains

the videos after
showing the caregiver

The researcher shows

caregivers artefacts
during training

The researcher asks

caregivers questions
throughout presentation

Caregivers are given

opportunities to ask
questions

The researcher
facilitates discussions
with caregivers

The researcher provides

caregivers with
feedback

The researcher explains

what is expected of the
caregiver during
activities

344
 APPENDIX P
P1 Training Booklet (English)

Caregiver Training Programme

THIS BOOKLET BELONGS TO:

345
P2 Training Booklet (Tshivenda)

346
 APPENDIX Q
Q1 Day 2 Training Presentation (English)

For the complete set of training slides, please go to :

https://drive.google.com/file/d/1o6t_GwFN10H1ynOonGHmfBc4jEod5pE4/view?usp=shar
e_link

347
 Q2 Day 2 Training Presentation (Tshivenda)

For the complete set of training slides, please go to :

https://drive.google.com/file/d/1o6t_GwFN10H1ynOonGHmfBc4jEod5pE4/view?usp=shar
e_link

348
 Q3 Day 2 Training Procedural Fidelity Script
Participant ID:
Date:
General Yes No Comments

Setting up
equipment

Greetings

Scheduling of the
day

Discussion about
previous day’s
presentation

Homework
activity
discussion

Re-cap of the
previous day
topics

Objectives of day
2 strategies
explained

The researcher
explains what is
expected of the
caregiver for
homework
activities

The researcher
ends the day by
thanking the
caregivers

349
Offering Yes No Comments
communication
opportunities

The researcher
introduces the topic

The researcher defines

concepts

The researcher
demonstrates strategies
to the caregivers

The researcher explains

the videos after
showing the caregiver

The researcher asks

caregivers questions
throughout presentation

Caregivers are given

opportunities to ask
questions

The researcher
facilitates discussions
with caregivers

The researcher provides

caregivers with
feedback

The researcher explains

what is expected of the
caregiver during
activities

350
Mnemonic Yes No Comments

The researcher introduces

the mnemonic to the
caregiver

The researcher facilitates

discussions with
caregivers

The researcher provides

caregivers with feedback

The researcher
demonstrates strategies to
the caregiver

The researcher explains

the videos after showing
the caregiver

The researcher asks

caregivers questions
throughout presentation

Caregivers are given

opportunities to ask
questions

351
 APPENDIX R
Verbal Rehearsal of Strategy Recording Form

Participant ID:
Yes No
Offering communication opportunities was explained
Examples for offering communication opportunities provided
Modelling Aided language input was explained
Examples provided
Waiting for the child to respond for 6-8 seconds was explained
Responding to the child's communication behaviour was explained
Examples of how caregivers can respond to a child
If the child does not respond mentioned
The caregiver will prompt the child on how to respond
The caregiver will respond to the child's prompted respond

Total number of Yes

responses
Total number of items 10

Percentage %

352
 APPENDIX S
Guided Practice With Feedback Session Procedural Script

Participant ID:_____________ Session: __________

Correctly Omitted or
completed incorrectly
completed

The researcher plays the video of

the intervention probe back to the
caregiver on her laptop.

The researcher provides the

caregiver with feedback based on
the discussion.
- By asking them what they
did well
- provide feedback

- ask what they could

improve upon
- provide feedback

- replay the video to

demonstrate
- provide feedback

Total number of items

correctly completed
Total number of items 7

Percentage

353
 APPENDIX T
T1 Post Intervention Survey
Participant ID:

Statements Strongly Agree Not sure Disagree Strongly

agree disagree
Ndi A thina Ndi khou
Ndi kho khou vhutanzi hanedza Ndi khou
tenda nga tenda dadadza
maanda

1. I clearly understood all

aspects of the training. Ndo pfesesa
zwothe zwe nda pfumbudziwa
ngazwo
2. The training helped me gain
knowledge about communicating
with my child. U pfumbidzwiwa
hanga zwo nthusa u vha na zwa u
davhidzana na nwana wanga
3. The training helped me gain
skills in communicating with my
child.U pfumbidzwiwa hanga zwo
nthusa u guda zwikili zwa u
davhidzana na nwana wanga
4. As a result of the training my
child’s communication has
improved. Nga murahu ha musi ndo
pfumbudziwa, huna tshanduko kha
kudavhidzanele kwa nwana wanga.
5. If I use these strategies daily,
my child’s communication skills
will improve. Nda nga shmisa
mbekanya-maitele hedzi duvha linwe
na linwe zwi do ita uri
kudavhidzanele kwa nwana wanga
kwu khwinifhale
6. Offering communication
opportunities is an acceptable
strategy for me to use when
communicating with my child.
Mbekanya-maitele ya netshedza
nwana zwikhala zwa u udavhidzana
ndi ya kwayo musi ndi kho
davidzana na nwana wanga
7. Point talking is an acceptable
strategy for me to use when
communicating with my child.
Mbekanya-maitele ya u amba nga u
sumba kwa nwana ndi ya kwayo
musi ndi kho davidzana na nwana
wanga

354
Statements Strongly Agree Not sure Disagree Strongly
agree disagree
Ndi A thina Ndi khou
Ndi kho khou vhutanzi hanedza Ndi khou
tenda nga tenda dadadza
maanda

8. Responding to my child is an
acceptable strategy for me to use
when interacting with my child.
Mbekanya-maitele ya kufhindulele
kwa nwana ndi ya kwayo musi ndi
kho davidzana na nwana wanga
9. I am willing to continue using
the strategies I learnt in the training.
Ndo di imisela u isa phanda na u
shumisa mbekanya-maitele dze nda
guda.
10. I am willing to teach other
family members to use the strategies
I learnt in the training. Ndo di
imisela u gudisa vhanwe vha mirado
ya muta wahashu mbekanya-maitele
dze nda guda.
11. Using the strategies that I
learnt will take too much of my
time. U shumisa mbekanya-maitele
dze nda guda zwi do nlela tshifhinga
tshinzhi.
12. Using the strategies that I
learnt will disrupt my family. U
shumisa mbekanya-maitele dze nda
guda dzi do disa pfudzungule mutani
wa hashu
13. Using the strategies that I
learnt will easily fit into my daily
routine. Zwi do leluwa u shumisa
mbekanya-maitele hedzi dze nda
guda kha maitele a duvha na duvha.
14. Using these strategies can
have negative effects on my child. U
shumisa mbekanya-maitele hedzi zwi
nga vha na masiandaitwa asi a
vhudi kha nwana wanga.
15. Using these strategies can
make my child uncomfortable. U
shumisa mbekanya-maitele hedzi dzi
nga ita uri nwana asi dzudzaneye.
16. My child and I interacted less
before the training. Nne na nwana
wanga ro vha ri sa davhidzani nga
maanda ndi saathu pfumbudziwa.

17. My child and I interact more

after the training. Nne na nwana
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 Statements Strongly Agree Not sure Disagree Strongly
agree disagree
Ndi A thina Ndi khou
Ndi kho khou vhutanzi hanedza Ndi khou
tenda nga tenda dadadza
maanda

wanga ri vho davhidzana nga

maanda nga murahu ha musi ndo
pfumbudziwa.

18. What did you like about the training? Ndi mini zwe vha zwifunesa nga u pfumbudziwa
nga mbekanya mushumo iyi?

19. What would you want to change about the training? Ndi mini zwine vha tama u
shandundukisa maitele a u pfumbudziwa nga ha mbekanyamushumo iyi?

20. Do you think there could be any positive consequences when you use the strategies
learned? Why? Vha vhona ungari hu nga vha na masiandaitwa avhudi musi vha tshi
shumisa mbekanya-maitele dze vha guda? Ndi nga mini vha tshi ralo?

356
21. Do you think there could be any negative consequences when you use the strategies
learned? Why? Vha vhona ungari hu nga vha na masiandaitwa asi avhudi musi vha
tshi shumisa mbekanya-maitele dze vha guda? Ndi nga mini vha tshi ralo?

22. How Satisfied were you with the training ? I was… (Vho fushea zwingafhani nga u
pfumbudziwa?)
Very satisfied (Fushea nga maanda)

Satisfied (Ndo fushea)

Neutral (vhukati)

Unsatisfied (a thingo fushea)

Very unsatisfied (a thongo fushea na

luthihi)

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T2 Post Intervention Survey Likert Scale Flashcards

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 APPENDIX U
Post intervention Commitment Statement Template

Vision (bono): A big plan for the future

Mission: what will you do in order to achieve your vision? What

are your goals that you would want to achieve (eg. In the next 4-
6 months)

Example

Vision: I would like to improve communication between caregivers and

their children living in south Africa by providing caregiver training in
groups of at least 10 caregivers at a time in their CP and/or
neurodevelopmental clinics in the nine provinces.

Mission

In order to realize the vision, will have to train caregivers in their district
and regional hospitals. The researcher will train the caregivers district by
district. In each hospital the researcher will:

- Raise awareness of AAC in the respective hospitals

- train caregivers on how to provide communication opportunities to their
children
- train caregivers on how to respond to their children’s communicative
behaviours and actions
- teach caregivers the importance of waiting 6-10 seconds during
communication for the child to respond
- teach caregivers how to model point talking with their children using
communication boards (with PCS, objects and/or tactile symbols)

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 APPENDIX V
Timed Event Recording Form
CCD____ Session ____ Date___________

Research Research Research Research Research

assistant assistant assistant assistant assistant
/Researcher /Researcher /Researcher /Researcher /Researcher

Time stamp/ DV Contingent Modelling Providing Child Child using

responding Aided communication communication augmented
language input opportunities turns output

5th (5:00-5:59)

6th (6:00-6:59)

7th (7:00-7:59)

8th (8:00-8:59)

9th (9:00-9:59)

10th (10:00-10:59)

11th (11:00-11:59)

12th (12:00-12:59)

13th (13:00-13:59)

14th (14:00-15:00)

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 APPENDIX W
W1 Expert Panel Information Letter and consent form

361
362
363
 W2 Expert Panel Question Template
Instructions to experts

This training programme is intended for Vhavenda caregivers living in and receiving SLP services in the hospitals in Vhembe
district.

Kindly familiarise yourself with the material and also the proposed training procedure. Then complete the tables here below to provide
feedback on (a) the training procedure and (b) the content of the proposed training programme.

You are able to access all training materials on Google drive shared folder. You will receive an email with an invitation to the Google
drive.

A. Training procedure
Kindly comment on the feasibility and appropriateness of the logistics and procedures proposed. Please provide any comments and
suggestions for change in the appropriate columns.

Intended training procedure Comments Suggestions for changes

• Caregivers will be met individually at their homes and children will be

screened. Suitable days for training will be agreed upon.

• Training will be done individually by the researcher at each caregiver’s

homes over the course of two days.

• The caregiver will be provided with a training booklet (see included)

• A PowerPoint presentation will be played and the researcher will

explain the topics. Caregivers will be able to follow in the training booklets.
Caregivers will have the opportunity to ask questions at any time.

• Activities will be conducted as indicated on the power point and the training
booklet. Breaks will be taken as appropriate. The total training time per day
is expected last 3,5 hours.

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 B. Content and material

Kindly comment on the content and material. You will be asked to comment specifically on
1) The objectives for each day

2) The content (section by section)

3) The activities proposed for each section

4) Videos embedded on specific slides

5) The proposed strategies that the caregivers will learn

6) The communication boards.

In each case, please consider specifically the clarity and also the appropriateness for the target population (Vhavenda caregivers with at least a
Grade 4 literacy level).

Aspect to be evaluated Comments Suggestions for changes

Day 1: Power point and training booklet pp. 3-17
Day 1: Objectives
(Slide 3)
Day 1: Session 1a:
Communication
(Slides 5 to 15)
(Booklet: pp. 3 – 7)
Please comment on content in general.
Activities
(Slide 6 & 15)
Day 1: Session 1a: AAC (Slides 16 to
35)
(Booklet: pp. 8- 12)
Please comment on content in general.

365
 Aspect to be evaluated Comments Suggestions for changes
Video
(Slide 18 &19)
Day 1: Session 1a: Point talking
(slides 31-35)
(Booklet: pp. 13 – 15)
Please comment on content in general and
appropriateness of the strategy.

Demonstration
(Slide 35)
Video
(Slide 34)
Day 1: Session 1b: Responding to your
child’s communication.
(Slides 36-44)
(Booklet: pp16 – 17
Please comment on content in general and
appropriateness of the strategy.

Activities
(Slides 43-44)
Video
(Slide 42)
Day 2: Power point and training booklet
Day 2: Objectives
(Slide 3)
Day 1 Recap
(Slides 5-11)
Please comment on content in general.

Activities:
(Slides 6,7,& 9)

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 Aspect to be evaluated Comments Suggestions for changes
Video(s) :
(Slides 10-11)
Day 2: Session 1a Offering opportunities
for communication
(Slides 12-24)
(Booklet: pp. 18 – 20)
Please comment on content in general and
appropriateness of the strategy.
Activities:
(Slides 17, 21, 24)
Video(s) :
(Slides 15,16, 22)
Waiting for your child to communicate
(Slides 26-28)
(Booklet: pp. 20-22)
Please comment on content in general and
appropriateness of the strategy.

Day 2: Session 1b: Putting it all together

(Slides 31 -32)
(Booklet: pp. 23 -27)
Please comment on content in general.

Activities:
(Slides 33-34)
Communication boards
Dressing /undressing

Morning routine (brushing and washing face)

Entertainment activity
Mealtime activity (for training)

367
Kindly reflect on the practicality and usability of the proposed programme within your context:

Kindly provide any further comments or reflections on the proposed training programme.

368
 APPENDIX X
Pilot Study – Graph of Results

369
 APPENDIX Y
Y1 SLP Recruitment Email

370
371
Y2 Caregiver Information Letter With Consent Form (English)

372
373
374
375
Y3 Consent Form

376